CNO Jurisprudence Exam Cheat sheet
1. Competencies – 101 in nine roles
Clinician
1. Client-centred
2. Holistic nursing assessment
3. Trauma-informed care
4. Analyses & interprets data
5. Develops care plan using critical inquiry
6. Evaluates effectiveness of care plan
7. Anticipates actual and potential health risks and possible united outcomes
8. Recognizes & responds - client safety
9. Recognizes & responds – deteriorating condition
10. Preps for & performs procedures
11. Applies pharmacology knowledge  safe medication practice
12. Evidence-informed practices of pain prevention & management
13. Therapeutic nursing interventions
14. Palliative & end-of-life nursing care
15. Maid – ethical, legal & regulatory implications – incorporate into nursing care
16. Principles of harm reduction re substance use & misuse
17. Epidemiological principles into care plans
18. Recovery-oriented mental health care
19. Mental health promotion in nursing care
20. Suicide prevention approaches in nursing care
21. Incorporates knowledge from health science
22. Incorporates knwldge frm nrsg since, social scs, humanities & health related research in care plan
23. Uses knowledge of the impact of evidence-informed RN practice on client health outcomes
24. Strategies to prevent, de-escalate and manage disruptive, aggressive or violent behaviour
25. Strategies to promote wellness, prevent illness & minimize disease & injury
26. Adapts practice in response to the spiritual beliefs and cultural practices of clients
27. Evidence-informed practices for infection prevention and control
Professional
1. Demonstrates accountability, accepts responsibility & seeks assistance within the scope of practice
2. Professional presence & confidence, honesty, integrity & respect
3. Exercises professional judgement
4. Maintain privacy & confidentiality & security
5. Recognizes, positional power & acts to reduce bias
6. Professional boundaries
7. Ethical issues
8. Professional judgment – maintains public trust - social media & information & communication tech
9. Adheres to self-re requirement
a. Identify learning needs
b. Develop learning plan
c. Seek & use new knowledge
d. Implement & evaluate the effectiveness of the learning plan
10. Fitness to practice
11. Adhere to duty to report
12. Distinguishes between mandates of reg bodies, prof assoc. & unions
13. Recognizes, acts & reports - harmful, near miss & no harm incidences
14. Recognizes, acts & reports actual & potential– workplace & occ health safety
Communicator 1. Introduces – full name & protected title
2. Active listening
3. Evidence-informed communication skills
4. Conflict resolution
5. Relational practice to adapt communication skills
6. Uses info & communication technologies (ICTs) to support communication
Collaborator
Coordinator
Leader
Advocate
Educator
Scholar
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Communicates effectively in complex & rapidly changing situation
Documents & reports clearly, concisely, accurately & timely
Demonstrates collaborative professional relationships.
Initiates collaboration to support care plannḡ & safe, continuous transitions frm health care facility
Det. own profess. & interprofess. role w/i team by considerḡ roles, responsibilities, & scope of pract.
Applies knwledge re scopes of pract of team members to strengthen intraprofessional collaboration
Contributes to team functn̄ ḡ by applyḡ group communicatn̄ theory, prnciples, & group process skills
Consults c̄ clients & team  adjustments required by ∆s in the availability of services/client health
Monitors client care to help ensure needed services happen at right time & in the correct sequence
Organizes own workload, assigns nursḡ care, sets priorities, & demonstrates effective time man. Skls
Demonstrates knowledge of the delegation process.
Participates in decision-making to manage client transfers within health care facilities.
Supports clts to navigate health care systms & other service sectors to optimize hlth & well-being.
Prepares clients for transitions in care.
Prepares clients for discharge.
Participates in emergency preparedness & disaster management.
Acquires knowledge of the Calls to Action of the Truth and Reconciliation Commission of Canada.
Integrates continuous quality improvement principles and activities into nursing practice.
Participates in innovative client-centred care models.
Participates in creating and maintaining a healthy, respectful, and psychologically safe workplace.
Recgnzes impct of orgnztn̄ al culture & acts to enhnce the qulity of a profssn̄ al & safe prctice envrnmt
Demonstrates self-awareness through reflective practice and solicitation of feedback.
Takes action to support culturally safe practice environments.
Uses and allocates resources wisely.
Provides constructive feedbck to promote professional growth of other members of hlth care team.
Demonstrates knowledge of the hlth care system & its impact on clt care & professional practice.
Adapts practice to meet client care needs within a continually changing health care system.
Recognizes and takes action in situations where client safety is actually or potentially compromised.
Resolves questions about unclear orders, decisions, actions, or treatment.
Advocates for the use of Indigenous health knowledge& healing practices
Advocates for health equity for all, particularly for vulnerable and/or diverse clients & populations.
Supports environmentally responsible practice.
Advocates for safe, competent, compassionate and ethical care for clients.
Supports & empowers clients in makg informed decisions re health care, & respects their decisions.
Supports healthy public policy and principles of social justice.
Assesses understandḡ & ability to be an active participant in own care, & facilitates strategies if not
Advocates for clt’s rights & ensures infrmd consent, guided by legislatn̄ , practice standrds, & ethics.
Uses knwldge of populatn̄ hlth, determinants of hlth, primary hlth care & hlth promotn̄  hlth equity
Assesses client’s understanding of informed consent, & implements actns when unable to provide
Demnstrts knwldge of substitute decisn mker’s role in providg informd consent & decision-makg care
Uses knowledge of health disparities and inequities to optimize health outcomes for all clients.
Develops an education plan with the client and team to address learning needs.
Applies strategies to optimize client health literacy.
Selects, develops, and uses relevant teaching and learning theories and strategies
Evaluates effectiveness of health teaching and revises education plan if necessary.
Assists clts to access, review & evaluate info retrieved usḡ info & communicatn technologies (ICTs).
Uses best evidence to make informed decisions.
Translates knowledge from relevant sources into professional practice.
Engages in self-reflection  cultural humility and create culturally safe environments
Engages in activities to strengthen competence in nursing informatics.
Identifies & analyzes emergḡ evidence & technologies that may change, enhance, / support hlth care.
Uses knwldge re current & emergḡ community & global hlth care issues & trends  clt hlth outcmes
Supports research activities and develops own research skills.
Engages in practices that contribute to lifelong learning.
 Safe, competent, ethical, compassionate, & evidence-informed  client centred
B. Practice standard
a. Professional Standards
1. Accountability: ensuring practice & conduct meet legislative requirements & professional standards
2. Continuing Competence: participate in CNO’s Nurses of Ontario’s Quality Assurance (QA) Program
Competence: = the nurse’s ability to use his/her knowledge, skills, judgment, attitude, values and beliefs to perform
in a given role, situation and practice setting.
3. Ethics: ethical care means promoting the values of client well-being, respecting client choice, assuring privacy &
confidentiality, respecting the sanctity and quality of life, maintaining commitments, respecting
truthfulness and ensuring fairness in the use of resources – also includes acting with integrity, honesty
and professionalism
b. Ethics practice standard
Values important in providing nursing care in Ontario:
1. Client well-being
2. Client choices
3. Privacy and confidentiality
4. Respect for life
5. Maintaining commitments: to client, oneself, colleagues, nursing profession, team
members/colleagues, quality practice setting
6. Truthfulness: speaking or acting without intending to deceive (other cultures may view this
differently)
7. Fairness: allocating health care resources on the basis of objective health-related factors
Approach to a dilemma:
1. Assessment/description of situation
2. Plan/approach
3. Implementation/action
4. Evaluation/outcome
4. Knowledge: possesses, through basic education and continuing learning, knowledge relevant to her/his
professional practice.
5. Knowledge Application: continually improves the application of professional knowledge.
c. Therapeutic Nurse-Client Relationship
1. Trust
2. Respect: recognition of the inherent dignity, worth & uniqueness of everyone
3. Professional intimacy
4. Empathy
5. Power: misuse of power imbalance is abuse (verbal, emotional, physical, sexual, financial or neglect)
Standard statement:
1. Therapeutic communication:
 to establish, maintain, re-establish & terminate nurse-client relationship
2. Client-centred care:
 all professional behaviours and actions meet the therapeutic needs of the client
3. Maintaining boundaries:
 not accepting gift unless not doing so will harm the nurse-client relationship
4. Protecting the client from abuse:
 ensuring abuse is prevented, or stopped and reported
* Can’t nurse someone you have power of attorney for
Warning signs of crossing a boundary
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spending extra time with one client beyond his/her therapeutic needs;
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changing client assignments to give care to one client beyond the purpose of the primary nursing care delivery
model;
feeling other members of the team do not understand a specific client as well as you do;
disclosing personal information to a specific client;
dressing differently when seeing a specific client;
frequently thinking about a client when away from work;
feeling guarded or defensive when someone questions your interactions with a client;
spending off-duty time with a client;
ignoring agency policies when working with a client;
keeping secrets with the client and apart from the health care team;
giving a client personal contact information unless it’s required as part of the nursing role; and
a client is willing to speak only with you and refuses to speak with other nurses.
When a colleague’s behaviour crosses a boundary -Address with the colleague:
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what was observed;
how that behaviour is perceived;
the impact on the client; and
the College’s practice standards.
Can’t speak to the colleague, or colleague see’s no problem 
a) speak to colleague’s supervisor
b) put concerns in writing – date, time, witnesses, client initial or file #
Still not resolved  further action needed it should include:
a) informing the client of his/her rights and
b) sending a letter describing the concerns to
 the next level or
 the highest level of authority in the agency, or
 reporting the matter to the College.
If witness another nurse of member of the health care team abusing a client – must take action
a) intervene (research shows that after that the abuse stops)
b) MUST report any incident of unsafe practice or unethical conduct by a health care provider to the employer
or other authority responsible for the health care provider.
c) In all cases, the nurse must inform the client of his/her right to contact police.
Certain legislation requires further reporting of abuse.
The Regulated Health Professions Act, 1991 requires regulated health professionals to report the
sexual abuse of a client by a regulated health
professional to the appropriate college.
The Child, Youth and Family Services Act, 2017 requires reporting suspected child abuse to the
Children’s Aid Society.
Maintaining a Quality Practice Setting: supports nurses in providing safe, effective and ethical care (pg 13)
d. Confidentiality and Privacy – Personal Health information standard
1. Personal Health Information Protection Act, 2004 (PHIPA) permits the sharing of personal health
information among health care team members to facilitate efficient and effective care – don’t have to work for
the same facility
 Client does not have to be names for info to be considered personal health information
 A personal record containing a note from a physician or an NP supporting an absence form work in not
considered personal health information, but description of symptom, and treatment would be
o Note can be shared only if health information is separated from the note
 Care givers can only use the information for the purposes they identified when requesting it from the Health
information custodian (HIC)
 “collection” = gathering, acquiring, receiving or obtaining or PHI
 Only collect as much as is needed for the purpose of the collection
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o PHI can be collected indirectly without consent if there is a question as to the accuracy or when
getting consent would affect the timeliness of the care (Act lists when PHI can be obtained from
someone other than the client)
o There are some disclosures that do not require consent
 To manage risk
 To support quality of care programs
 To allocate resources
 To obtain payment
 To do research (research plan must have been approved by an ethics board)
 Disclosure without consent is also permitted when:
o It is needed to provide health care and consent cannot be obtained quickly
o Contact a relative or friend of an injured incapacitated or ill client for consent
o To confirm that a client is a resident or client in a facility, provide his/her location and
comment on his/her general health status (unless express request not to)
o To eliminate or reduce a significant risk of harm to a person
o Consent can be implied when conditions met:
 posting notice/providing brochure describing purpose, use, and disclosure
o Express consent: no specific form required, can be over the phone or electronically if nurse can identify the
person
 Required when PHI is to be disclosed (disclosure = making info available or releasing it to another
HIC or person)
 outside the health care team eg. to an insurance company
 For purposes other than providing, or helping to provide care
 Used for fundraising
 Collected for marketing research or marketing activities
o Substitute decision-makers
 Rules for who can act, eg spouse, child under 16 who can’t answer questions or make decision, appeal
routes for those found incapable and if there is conflict
PHI belong to the client, but housed in healthcare facility
Inform client of right withdraw consent,
Client has right to keep some information from being shared – lockbox provision  must advise that some
relevant information has not been shared
Client has right of access except if it was QA generated, raw data from standardized psychological test or
assessments, presents risk of serious harm to treatment or recovery or other, would reveal identity of a
confidential source
Client has right to correct
o Request must be oral or in wiring, but correction procedure in the act only apply to written requests,
can make request if granted access to record, Clients can not restrict the collection, use or disclosure of
their PHI that is required by law or professional standards
o Request for correction may be refused if:
 Frivolous, vexatious, or made in bad faith
 Custodian did not create the record, and doesn’t have sufficient, knowledge, expertise or authority
to make correction
 The information is a professional opinion or observation make in good faith
o There must be procedures and policies in place to process such requests
 Client’s can complain to an organization’s contact person, the Information and Privacy
Commissioner about refusals to access request or other breaches of PHIPA
Independent practice or non-health care setting  Nurse may be considered HIC  responsible
for the personal health information in their custody and control, and must take certain steps to
safeguard it. Compliance under the Act includes the following:
designating a contact person to facilitate compliance with the Act and to respond to requests,
inquiries and complaints from the public;
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providing a written public statement generally describing information practices, how to reach
the contact person, the process for accessing records or requesting corrections, and the
complaint process for clients;
ensuring information practices comply with the Act and its regulations;
ensuring information is accurate, complete and up-to-date; and
ensuring information is secure.
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 Professional misconduct: giving information about a client to a person other than the client or his or
her authorized representative, except with the consent of the client or his
or her representative, or as required or allowed by law
2. Quality of Care Information Protection Act, 2016 (QOCIPA) purpose is to promote open discussion of
adverse events, peer review activities and quality of care information while protecting it from being used
in litigation or accessed by the client
 CNO’s Quality Assurance Program cannot be used in legal proceedings
e. Medication Practice Standard
1. Authority: require an order for a medication when a controlled act is involved, administering a prescription
medication, or the law that applies to that practice setting requires it
Orders must be clear, complete, appropriate
2. Competence: Knowledge, skill, judgment (evidence-informed)
3. Safety: promote safe care & contribute to a culture of safety (minimize misuse & drug diversion)
e. Documentation
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Reflects the client’s perspective, identifies the caregiver, promotes continuity of care
Clear picture of needs, actions, outcomes (evaluation of those actions)
Failing to keep records as required, falsifying a record, signing or issuing a document that the member knows
includes a false or misleading statement, and giving information about a client without consent all constitute
professional misconduct under the Nursing Act, 1991
Interrelationship of:
o Organization supports: policies & procedures, decision support tools, enviro. & human res. supports
o Client communicates: needs, goals, perspective, choice and preference
o Nurses document: assessment, planning, implementation, evaluation
o CNO supports: practice standards, practice guidelines, fact sheets
 Result: complete doc. that demonstrates: communication, accountability, legislative requirements
Nurses’ accountability when documenting:
1. Communication: accurate, clear and comprehensive picture of needs, interventions & outcomes
2. Accountability: client care is accurate, timely & complete
3. Security: maintaining confidentiality, following info retention & destruction policies & procedures
Must demonstrate knowledge, skill, judgment and attitude required of health professionals.
f. Decisions About Procedures and Authority
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Nurses may consider accepting delegation of any controlled act procedure not authorized to nursing as long as
they comply with requirements in regulation
o Delegation is the formal process that transfers the authority to perform a controlled act
o Direct order – an individual practitioner directs a specific intervention, specific time, specific client
 Written, or oral (over the phone)
o Directive – order that may be implement when specific conditions are met for many clients
 Always written
Practice Guideline – Directives
Note: Orders are required when:
 a procedure falls within one of the controlled acts authorized to nursing when
the nurse does not have the authority to independently decide to perform (i.e.,
initiate) the procedure;
 required under the Public Hospitals Act, Healing Arts Radiation Protection Act
or other legislation governing client services; and
 requird by a practice-settḡ policy / as agree on within the physician’s plan of care
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Initiation – nurse initiated, requirements are in appendix D (Public Hospitals Act, regulation 965 requires
nurse in hospitals to have orders for these)
Professional misconduct. The Nursing Act includes regulations that identify professional
misconduct. Some of the professional misconduct regulations relevant to a nurse’s decision to
accept delegation and perform procedures include the following.
1. Contravening a standard of practice of the profession or failing to meet the standard of practice
of the profession.
2. Directing a member, student or other health care team member to perform nursing functions
for which she or he is not adequately trained or competent to perform.
3. Failing to inform the member’s employer of her or his inability to accept specific responsibility
in areas in which specific training is required or for which the member is not competent to
function without supervision.
4. Contravening a provision of the Nursing Act, the Regulated Health Professions Act, 1991, or
regulations under either of those acts
Standards Statement
1. Appropriate health care provider
 Must determine if it is appropriate for nurse to perform the procedure
o Must ensure consent and that client know the nurse will perform the procedure
2. Authority
 Are there orders, is delegation necessary
3. Competence
 In both the cognitive and technical aspects of a procedure
o Must determine of the procedure for the specific client and the specific situation
o Knowledge of the following components of the procedure
 Purpose
 Indications
 Contraindications
 Risk to the client
 Expected outcomes
 Actions to take if complications occur
 Health teaching and decision support
o Apply knowledge, best evidence, skill, judgment and appropriate authority to make and act on
decisions required during the procedure
o Consulting when reached limits of knowledge, skill, judgment
o Communicating with team as needed for safe, effective and ethical care
o Reflecting on and continuously improving knowledge, skill and judgment
4. Managing outcomes
 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
o Identify risk and outcomes
o Determine if management of them is within knowledge, skill, judgment
 Managing outcome independently
o Identify required resources to management outcome and perform procedure
 Advocating for required resources
o Declining to perform if can’t manage outcomes or resources not available
Maintaining a Quality Practice Setting (page 12)
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Care delivery process
Leadership
Organizational supports
Communication systems
Facilities and equipment
Professional development systems
Practice Guidelines
A. The Client, the Nurse, and the Environment
 Guiding principle: the goal of professional practice is to obtain the best possible outcome for clients
 Legal Scope Of Practice: The Regulated Health Professions Act, 1991 (RHPA) & the Nursing Act, 1991
o Components of the legislative framework are a scope of practice statement and a list of controlled acts
authorized to nursing.
Controlled Acts Authorized to Nurses (Nursing Act, 1991):
 performing a prescribed procedure below the dermis or mucous membrane
 administering a substance by injection or inhalation
 putting an instrument, hand or finger:
◗ beyond the external ear canal
◗ beyond the point in the nasal passages where they normally narrow
◗ beyond the larynx
◗ beyond the opening of the urethra
◗ beyond the labia majora
◗ beyond the anal verge, or
◗ into an artificial opening in the body.
 dispensing a drug
 treating, by means of psychotherapy technique, delivered through a therapeutic relationship, an
individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory
that may seriously impair the individual’s judgement, insight, behaviour, communication or social
functioning.
 The nurse is accountable for:
o her or his actions and decisions
o knowing and understanding the roles and responsibilities of other team members, and collaborating, consulting
and taking action on client information when needed
o taking action to ensure client safety, including informing the employer of concerns related to the conduct and/or
actions of other care providers, AND
o collaboratḡ c̄ clients, c̄ each other & c̄ members of interprofessional care team for benefit of client
 The designated nursing authority is accountable for
(which is the nurse with the highest level of authority for nursing in the practice environment)
o Ensurḡ mechanisms are in place such as policies, prcdures, guidelines & other resources to support:
 Utilizatn̄ decisn̄ s that consider clt, nurse & environment factors, & that are evidence-based
 nurse collaboration and consultation
 clear and well-understood role descriptions
 professional nursing practice, AND
 continuity of client care.
 Three-Factor Framework: effective decisn̄ s re RN/RPN to match c̄ client consider 3 equal factors:
1. The client
i. complexity
 0 to which a client’s condition & care requirements are identifiable & established
 the sum of the variables influencing a client’s current health status, AND
 the variability of a client’s condition or care requirements.
ii. predictability
 the extent to which a client’s outcomes and future care requirements can be anticipated.
iii. risk of negative outcomes
 the likelihood that a client will experience a negative outcome as a result of the client’s health condition or
as a response to treatment.
2. the nurse
 The factors that affect a nurse’s ability to provide safe and ethical care to a given client include:
 leadership, decision-making and critical-thinking skills.
 Other factors include:
 the application of knowledge,
 knowing when and how to apply knowledge, AND
 having the resources available to consult as needed.
o Consultation results in one of the following:
a) the nurse receiving advice and continuing to care for the client
b) the nurse transferring an aspect of care to the consultant
c) the nurse transferring all care to the consultant.
o NOTE: When a care provider assignment involves the expectation of consultation:
 nurses must assess that the required consultative supports are available.
 When supports inadequate to meet client needs & ensure quality care:
o nurses must take appropriate action.
 Whenever the need for consultation exceeds the efficient delivery of care:
 it is most likely that the client requires an RN to provide all care.
3. the environment
 Environment factors include:
o practice supports, consultation resources that support nurses in clinical decision-making
o the stability/ predictability of the environment. Practice supports and consultation resources support
nurses in clinical decision-making.
 The less available the practice supports and consultation resources are,
 the greater the need for more in-depth nursing competencies & skills in the areas of
o clinical practice, decision- making, critical thinking, leadership, research utilization and
resource management.
 The application of the three-factor framework will help decision- makers determine which roles and activities are
not appropriate for autonomous RPN practice.
o Examples include, but are not limited to, the following:
• triage nurse
• circulating nurse
• administering conscious sedation / monitoring sedated clients (includes deep sedation & general anaesthesia)
Appendix A: Quality Practice Settings pg 12
Care Delivery processes
Communication systems
Leadership
Organizational supports
Professional development systems
Response systems to external demands
Facilities and equipment
B. Directives (aka medical directives) [return to Decisions about procedures and authority]
 Order = prescription for a procedure, tx, drug or intervention
o Types:
 Direct order = applies to an individual
 by a spcfc individ. (eg MD, midwife, dentist, chiropodist, NP, RN initiatḡ a controlld act)
 for a specific intervention
 to be administered at a specific time
 can be oral or written
 Directive = applies to more than one individual
 When specific condition are met AND
 When specific circumstances exist
 Always written (for this document, means by an MD or NP)
o When required (i.e. when is an order required)
 In any of the following
 when a procedure falls within one of the controlled acts authorized to nursing, in the absence of
initiation e.g.:
o administering a substance by injection or inhalation,
o performing a procedure below the dermis, or
o puttḡ an instrmnt/hand/fingr bynd a bdy orifice / bynd an artificial openḡ into the body
o dispensing a drug;
 when a procedure does ø fall within any controlld act, but is part of a medical plan of care;
 when a procedure falls within one of the controlled acts ø authorized to nursing;
 when prcdre/tx/interventn̄ is ø under Rgltd Hlth Professn̄ s Act, 1991, but other legislatn̄ eg:
o X-rays under the Healing Arts Radiation Protection Act, or
o ordering laboratory tests.
 Directives MUST include:
o name & description of the procedure(s)/ tx(s)/intervention(s) being ordered;
o specific clt clinical conditn̄ s & situational circs that must be met < prcdr(s) can be implmntd;
 degree to which these are specified with depend on:
 patient population
 nature of the orders involved
 expertise of the health care professionals implementing the directive
o clear identification of the contraindications for implementing the directive;
o name & signature of NP/physician approving, & taking responsibility for, the directive; AND
o date & sgntre of administrative authority approvḡ the directive; eg ICU Advisory Committee
Note: the whole team would ideally be involved in writing directives  need to determine if patient needs to
be assessed by NP/physician before a procedure is implemented, if so, needs to be a direct order
 What policies are needed < Directives Developed and Used
NOTE: facility’s governḡ board, develops & ensures appropriately implemented
(Strongly recommended these are in place before directives in use at a facility)
o identificatn̄ of types of procedure(s) that may be ordered via a directive ie which.
 types of procedure(s) require a direct order, AND
 may be implemented when health care professional has verified conditn̄ s & circs met;
o determinatn̄ of the involvement of the NP/ physician responsible for the care of the client,
 e.g. when a directive may be implemented prior to the NP/physician seeing the client;
o identification of who may implement a directive,
 including any specific educational reqs, designations or competencies
 eg only RNs in a certain department who have completed a continuing education course, only RNs
who have completed an in-service program, all RNs, or all RNs and Registered Practical Nurses
[RPNs], etc.);
o identification of the NPs or physicians to whom a directive applies.
 whether applies to clients of all NPs/physicians or only those of selected NPs/physicians;
o development of a feedback mechanism, including a defined communications path.
 enables health care professional implementḡ directive to
 identify NP or physician responsible for the care of the client, AND
 to query the order(s) contained within the directive if clarification is required;
o documentatn̄ reqs on the part of the health care professional implementing a directive; AND
o identification of tracking/monitoring methods
 to identify when directives implmntd inapprpriatly or resultḡ in unanticipatd outcomes
 Responsibilities of NP/physician who writes an order (direct order / directive)
o knowing risks of performing the intervention being ordered;
o knowing predictability of the outcomes associated with the intervention;
o knowing 0 to which safe managem’t of poss outcomes requires NP/MD involvem’t/ intervention;
o ensuring that appropriate medical resources are available to intervene as required; AND
o ensuring that informed consent has been obtained.
 Responsibilities of Health Care professional implementing directive
o clarifying that informed consent has been obtained;
o assessing clt to determine if specific clt conditn̄ s & situational circs identified in directive met;
o knowing the risks to the client of implementing the directive;
o possessing the knowledge, skill &judgment required to implement the directive safely;
o knowing the predictability of the outcomes of the intervention;
o determining if management of the poss outcomes is within the scope of her/his practice;
 if so, if is competent to provide such management
 if not, whether the appropriate resources are available to assist as required; AND
o knowing how to contact NP/MD responsible for care of the client if orders require clarification.
C. Authorizing Mechanism
 An authorizing mechanism—an order, initiation, directive or delegation — is a means specified in legislation, or
described in a practice standard or guideline, through which nurses obtain the authority to perform a procedure or
make the decision to perform a procedure.
o Legislation Governing Nursing Practice:
 Regulated Health Professions Act, 1991 (RHPA)
 Scope of Practice statement
The practice of nursing is the promotion of health and the assessment of, the provision of
care for and the treatment of health conditions by supportive, preventive, therapeutic,
palliative and rehabilitative means in order to attain or maintain optimal function.
 Series of controlled /authorized acts for each profession (those of nursing listed elsewhere)
o An R(P)N is authorized to perform these controlled acts under the following two conditions:
 if initiated in accordance with the conditions identified in the regulation; OR
 if ordered by a physician, dentist, chiropodist, midwife or Nurse Practitioner (NP).
 Nursing Act, 1991
o Other acts that govern the practice of health care, including nursing, in Ontario
 Public Hospitals Act;
 Healing Arts Radiation Protection Act;
 Laboratory and Specimen Collection Centre Licensing Act;
 Mental Health Act; and
 Fixing Long-Term Care Homes Act, 20214
 Authorizing Mechanisms
o Orders = a prescription for a procedure, treatment, drug or intervention.
 required when:
 a procedure falls w/i one of the controlled acts authorized to nursḡ, when a nurse has ø initiated the act;
 a procedure does not fall within any controlled act, but is part of a medical plan of care;
 a procedure falls within one of the controlled acts not authorized to nursing; OR
 a procedure/treatment/interventn̄ is not includd in the RHPA, but is includd in another piece of legislatn̄
o Direct Orders
 May be written or oral
 Verbal orders must only be used in emergency situations or when the prescriber is unable to document the
order such as in the operating room
o Directives
 See section on directives
o Initiation
 Under the Act, R(p)Ns who meet certain conditions have the authority to initiate specific controlled acts.
 When initiating a controlled act, an RN or RPN must:
o assess the client and identify the problem;
o consider all of the available options to address the problem;
o weigh the risks and benefits of each option considering the client’s condition;
o decide on a course of action;
o anticipate the management of potential outcomes; AND
o accept accountability for deciding that the particular procedure is required and for ensuring that any
potential outcomes are managed appropriately.
 R(P)Ns who consider initiating procedures advised to clarify scope of their roles and responsibilities
 If within the scope of role and competence, and is not prohibited by legislation or organizational policy:
o initiating R(P)N may perform the procedure, OR
o an RN may write the order for the procedure and another nurse may perform it.
 Conditions for initiating controlled acts
1. Competence - The person who is initiating must have the
 knowledge, skill and judgment to:
o perform the procedure safely, effectively and ethically
o determine whether the client’s condition warrants the performance of the procedure.
2. Client Factors - The person who is initiating must:
 have a nurse-client relationship with the client
 determine that the clt’s conditn̄ warrants the performance of the procedure havḡ considered:
o the known risks and benefits to the individual
o the predictability of the outcomes of performing the procedure, and
o other relevant factors specific to the situation.
3. Environmental supports - The person who is initiating must have the appropriate resources to:
 perform the controlled act safely &
 manage reasonably expected outcomes.
4. Documentation requirements - The person who is initiating must:
 document the initiation and outcome in the client chart.
5. A nurse’s accountabilities - The person who is initiating must:
 accept accountability for the decisn̄ to initiate the procedure & ensure that any potential outcomes
are managed.
 Restrictions on initiating controlled acts
o Although legal authority may exist, in practice other legislation or practice-setting policies may not allow
 For example, RNs and RPNs cannot initiate treatments in a hospital setting because the Public Hospitals
Act grants only physicians, NPs, midwives and dentists the authority to order treatments.
o Delegation
 When accepting delegation or delegating, it could be considered professional misconduct if the nurse:
 contravenes a stndrd of practice of the professn̄ or fails to meet the standard of practice of the professn̄
 directs a member, student or other member of the health care team to perform nursing functions
for which she/he is not adequately trained or competent to perform
 fails to inform the member’s employer of her/his inability to accept specific responsibility in areas in which
specific training is required, or for which the member is not competent to function without supervision,
and/or
 contravenes a provision of the Nursing Act, the Regulated Health Professions Act, 1991 or regulations under
either of those acts.
 Who can delegate, which acts can be delegated and who can accept delegation
 General, Extended or Emergency Assignment Classes  can delegate & accept delegation
 Nurses in the Temporary Class cannot delegate or accept delegation.
 Nurses in the Special Assignment Class cannot delegate, but may be able to accept delegation.
 Restriction on delegating
 R(P)Ns cannot delegate the controlled acts of
o dispensing a drug OR
o treating by treating, by means of psychotherapy technique, delivered through a therapeutic relationship,
an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory
that may seriously impair the individual’s judgement, insight, behaviour, communication or social
functioning.
 NPs cannot delegate
o prescribing, dispensing, selling or compounding medication
o ordering the application of a form of energy
o setting a fracture or joint dislocation
o treating, by means of psychotherapy technique, delivered through a therapeutic relationship, an
individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory
that may seriously impair the individual’s judgement, insight, behaviour, communication or social
functioning.
 Sub-delegation
o Nurses can only delegate those acts which they have the authority to perform.
 cannot delegate an act that has been delegated to them.
o Nurse can only accept delegation from regulated health professional who are authorized to perform those
controlled acts by a health profession act governing their profession
 Delegation may or may not include an order, an order may or may not indicate a delegation
 Delegatn̄ provides the legal authority to prfrm a cntrlld act; an order outlines how to perform it.
For example, an R(P)N may obtain the authority to adjust a cardiac pacemaker through delegation:
 expectations for delegation met + parameters for adjustḡ pacemaker = order within delegation
 delegation document, ø parameter  R(P)N requires a direct order to perform adjustment
 Delegation by nurses
 Usually to UCPs such as family members or other regulated health professionals
o Can be oral/written & appropriate documentatn̄ of the particulars of the delegatn̄ must be maintained
o EXCEPTION in RHPA allows UCPs to perform controlled acts if they are considered routine ADLs
 Procedures are considered to be routine activities of living when the need for, response to, and
outcome of the procedure have been established over time and are predictable:
 Requirements for delegating (all must be present)
 Req 1: nrse has the authority under the Nursing Act to perform the controlled act (CA).
 Req 2: nrse has knowledge, skill & judgment to perform the controlled act safely &ethically.
 Req 3: nrse has a nurse-clnt relatn̄ship c̄ the clt for whom the controlled act will be performed.
 Req 4: nrse has considered if the delegatn̄ of the CA is appropriate, keeping in mind the best interests &
needs of the client.
 Req 5: nrse takes reasonable steps to ensure satisfied that sufficient safeguards & resources are avail. to the
delegatee so that the controlled act can be performed safely & ethically.
 Req 6: nrse considered if the delegatn̄ should be subject to any conditions to ensure that it is performed
safely & ethically, & has made the delegatn̄ subject to conditn̄s, if applicable.
 Req 7: After taking reasonable steps, nrse is satisfied that the delegatee is a person who is permitted to
accept the delegation and is:
o a nurse who has a nurse-client relationship with the client (would be NP delegating)
o a health care provider who has a professional relationship with the client
o a person in the client’s household, or
o a person who routinely provides assistance or treatment for the client.
 Req 8: nurse must be satisfied that delegate has:
1. When delegatee is a nurse or other regulated health professional:
o the knowledge, skill & judgment to perform the controlled act safely & ethically.
2. When the delegatee is not a regulated health professional,
o knowledge, skill & judgment to perform the controlled act safely & ethically AND
o that the delegation is appropriate for the client.
 Req 9: If the nurse has delegated a controlled act but has reasonable grounds to believe that the delegatee
no longer has the ability to perform the controlled act safely and ethically, the nurse must
immediately cease to delegate the controlled act to that delegatee.
 Req 10: The delegating nurse shall:
a) ensure that a written record of the particulars of the delegation is available in the place where
the controlled act is to be performed, before it is performed
or
b) ensure that a written record of the particulars of the delegation, or a copy of the record, is
placed in the client record at the time the delegation takes place or within a reasonable period
of time afterwards
or
c) record particulars of the delegation in the client record either at the time the delegation takes
place or within a reasonable period of time afterwards.
The particulars of delegation must include those mentioned in “Documenting the particulars of delegation”
below.
 Requirements for Accepting Delegation (all must be present)
 Req 1: nrse has the knowledge, skill and judgment to perform the controlled act safely and ethically.
 Req 2: nrse has a nurse-client relationship c̄ the client for whom the controlled act is to be performed.
 Req 3: The nurse has considered whether performing the controlled act is appropriate, keeping in mind the
best interests and needs of the client.
 Req 4: After taking reasonable steps, the nurse is satisfied that there are sufficient safeguards and resources
available to ensure that the controlled act can be performed safely and ethically.
 Req 5: nrse has no reason to believe that the delegator is not permitted to delegate that controlled act.
 Req 6: If the delegation is subject to any conditions, nurse has ensured that the conditions have been met.
 Req 7: Nurses who perform a controlled act that was delegated to them must record the particulars of the
delegation in the client record, unless:
a) a written record of the particulars of the delegation is available in the place where the controlled
act is to be performed or
(b) a written record of the particulars of the delegation, or a copy of the record, is in the client
record or
(c ) the particulars of the delegation have already been recorded in the client record.
 Documenting the particulars of delegation
 Any record of the particulars of a delegation must include:
(a) the date of the delegation
(b) the delegator’s name, if the controlled act was delegated to the nurse
(c) the delegatee’s name, if the controlled act was delegated by the nurse, and
(d) the conditions, if any, applicable to the delegation.
 Tools for Delegating, Accepting Delegation and Developing Directives
 The Federation of Health Regulatory Colleges of Ontario has developed resources
 Assigning, Supervising or Teaching a Procedure
 Assigning a procedure
o Assigning is determining or allocating responsibility for particular aspects of care that may include
controlled and non-controlled act procedures.
 Assigning care may require nurses to supervise aspects of care or teach procedures.
o RNs, RPNs & NPs c̄ the necessary knowledge, skill & judgment may assign care to other nurses or UCPs.
 Supervising a procedure
o Supervising is monitoring and directing specific activities of others for a defined period.
 Supervising does not include ongoing managerial responsibilities.
o RNs, RPNs and NPs may supervise others, includes:
 providing appropriate 0 of either direct or indirect supervision to the individual being supervised.
 It is based on the client’s condition, the nature of the procedure(s), the resources available in the
setting and the degree of competence of the person being supervised.
 Teaching a procedure
o Teaching is providing instruction, determining that a person is competent to perform a procedure and
evaluating the learning.
 Teaching is not equivalent to delegation because it does not involve the transfer of authority to
perform a controlled act.
D. Consent


Health Care Consent Act, 1996 (HCCA)
o All consent must be given by a capable person
 If person found incapable, must give client info re consequences of the finding
 Done in accordance c̄ governing body’s guidelines (see below steps to obtaining consent)
o No formal statement verifyḡ status necessary if family member is substitute decision maker
o Person’s wishes re tx, care facility, personal assit ser. Can be oral, written or implied
o Deals separately with (Nurses are accountable for obtaining consent for all three following):
 Consent to treatment
 Consent, assessing capacity to consent to tx MUST:
o relate to a specific treatment or plan
o be informed
o be voluntary
o not have been obtained through misrepresentation or fraud
 Assessing capacity to consent to a tx – responsibility of person proposing the tx
o who is also responsible for takḡ reasonable steps to ensure tx is ø admin. s̄ consent
 Minor adjustments to tx plan can for incapable be made s̄ getting consent again
 Other healthcare providers can get consent for tx plan on behalf of those involved in plan
 Must have consent for any treatment EXCEPT emergency situations
 Consent to a care facility
 If consent to admission to a care facility is requrd by law, only exception is a crisis situation
 Consent to a personal assistance service
 For either care facility or personal assistance service – evaluator determines capacity
o RN/RPN/NP can be an evaluator
o Client has the right to ask the Consent and Capacity Board (CCB) to review finding
o Consent is informed if, before giving it received:
1. info re tx that a reasonable person in the same circumstances would require
 info must include:
o nature of the tx
o expected benefits of tx
o material risks & side effects of tx
o alternative courses of action
o likely consequences of not having the tx
2. responses to requests for additional information re tx
Substitute Decisions Act, 1992 (SDA)
o Deals c̄ decision-making re personal care /property on behalf of continually incapable persons
 Formal appointment of a decision-maker through a power of attorney document
 Through office of the Public Guardian and Trustee (PGT) or court appointment
 Individual can designate a specific person in the event becomes incapacitated
 Person can also express wishes about kinds of decision or factors to guide decisions
o Powr of attorney for personal care  when mentally incpctted unless states otherwise
o Only trained capacity assessors can determine incapacity to make decision on an ongoing basis
o Provides a hierarchy to determine who is eligible to be a substitute decision-maker (SDM)
 POA for personal care (can include specific instructions re particular treatment decisions) is not
necessarily required to act as a SDM
 Spouse = married/cohabitating in conjugal rel for ≥ 2 years /parents of a child/ cohabitation
agreement under the Family Law Act
 Partners = lived together for at least one hear & have close personal relationship that is of primary
importance in both persons’ lives
 Relatives = related by blood, marriage or adoption
 Public Guardian and Trustee (PGT) = last resort, only appointed if no other suitable willing
 Treatment = anything done for a therapeutic, cosmetic or other health-related purpose
o Includes a course of treatment or plan of treatment


 Plan of treatment can include withholding/withdrawal of tx
o Does not include:
 Capacity assessment for tx, facility, personal assistance service
 Capacity assessment for property
 Taking health history
 Assessing/examining to determine general health condition
 Communicating an assessment/diagnosis
 Admitting to a hospital/other facility
 Providing a personal assistance service
 Assist c̄/supervision of hygiene, washing, dressing, grooming, eating,
drinking, elimination, ambulating, positioning, other ADLs
 Providing a treatment that in the circs poses little/no risk of harm
 Performing anything prescribed by the regulations
 BUT common law still requires consent for these activities
o Consent and Capacity Board (CCB) considers applications for review of:
 Findings of incapacity
 Appointment of a representative
 Direction regarding the best interests and wishes of an incapable person
Mental Health Act – This one is not covered, nor is Medical Assistance in Dying covered
steps to obtaining consent
1. Assess capacity
a. Definition of capacity
 Presumed capable re tx, admission, personal assistance services
o Entitled to rely on UNLESS reasonable grounds to believe otherwise
 Capable if:
 Understands the info relevant to making a decision
 Appreciates the reasonably possible consequences of decision/ ø decision
b. Age of consent
 No minimum age of consent  professional judgment
c. Role of evaluator
 Determines capacity for admission/personal assistance services
 May be person proposing, or identified by facility or agency polities
 Nurse/other health care professional can act as
d. Role of capacity assessor
 Assess capacity on those who need decisions made for them on a continuing basis
 RN/NP eligible to be cap assess  requires training approved by attorney general
e. Incapable person
 Consent obtained frm highest ranked available SDM frm HCCA hierarchy who is will
o If no one, Public Guardian and Trustee (PGT)
2. Provide emergency treatment / crisis admission
a. tx in an emergency
 can be provided immediately if
o Person capable and gives consent
o ø reason to believe ø want, delayprolng sufferg¯ apprnt exprncd /risk of ser. Bdly hrm &
 language barrier/disability AND reasonable efforts to overcome
o incapable c̄ respect to tx bu:
 SDM is avail to give consent
 SDM ø rdly avail., ø reasonably poss. to get consent/rfsl frm SDM / dly  risk of SBH
 Emergency =
o Person experiencing severe suffering OR
o At risk of sustaining serious bodily harm if tx ø administered promptly
 Examinations/diagnostic procedures (that = treatments) reasonably nesc. to determine if
emergency exists, can be done s̄ consent
b. Crisis admission
 Can be admitted to a care facility without consent if:
o Person deemed incapable AND
 Requires immediate admission as a result of a crisis AND
 Not reasonably poss to get immediate consent/refusal on behalf of incapacitated
 Reasonable efforts must have been made
3. Inform Client that a SDM will make decision
 Nurse needs to follow the specific guidelines relating to advising clients of their rights
 CNO’s guidelines are in Appendix A
Appendix A: Advocating for Clients
 Nurses obtainḡ consent have professional accountability
o to be satisfied client is capable of giving consent
o to act as clt advocate & help them understnd info relevnt to makḡ decisn̄ s to extent poss by clt’s capacity.
1. If proposing a tx/evaluating capacity re admission or personal assistance service decision  incapacity
 informs the client that a substitute decision-maker will be asked to make the final decision.
o communicated in way that considers particular circs of clt’s conditn̄ & nurse-clt relatn̄ shp.
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.
o If relates to the finding of incapacity, or choice of substitute decision-maker,
  informs clt of optn̄ s to apply to the CCB for a review of findḡ &/appointm’t of rep of choice
3. If client is uncomfortable with the finding of incapacity made by another health care practitioner,
 then the nurse explores and clarifies the nature of the client’s discomfort.
o If it relates to the finding of incapacity, or to the choice of substitute decision-maker,
  informs the health care practitioner who made the finding & discusses appropriate follow-up.
4. uses professional judgment & common sense to determine if client is able to understand the information.
 eg, a young child / client suffering advanced dementia ø likely to understand the info
o ø reasonable in these circs for nurse to inform clt that a SDM will be asked to decide on his/her behalf.
5. uses professional judgment to determine scope of advocacy services to assist client in exercising options.
 documents actions accordḡ to CNO’s Documentation, Revised 2008 practice standard & agency policy.
4. Identify SDM
Hierarchy of substitute decision-makers
1. Guardian of the person — appointed by the court.
2. Someone who has been named as an attorney for personal care.
3. Someone appointed as a representative by the CCB.
4. Spouse, partner or relative in the following order:
a. spouse or partner,
b. child if 16 or older; custodial parent (who can be younger than 16 years old if the decision is
being made for the substitute’s child); or Children’s Aid Society;
c. parent who has only a right of access;
d. brother or sister;
e. other relative.
5. PGT is the substitute decision-maker of last resort in the absence of any more highly ranked
substitute, or in the event two more equally ranked substitutes cannot agree.
 A spouse, partner / relative present when the tx is proposed may make the decision UNLESS:
o a specially appointed substitute is available; OR
o a spouse, partner or relative with a higher priority is avail & willing
 Health care practitioners permitted to rely on assertion from person claiming to be the SDM
o formal statement that person is the SDM ø nec. to give/refuse consent to tx, facility, PAS
5. Obtain consent from the SDM
 SDM decisions to be based on client’s known wishes (expressd when ≥ 16 yo & capable)
o If ø known OR impossible to be complied with  in best interest of the client considering:
 In the case of a treatment
 client’s values and beliefs;
 impact of the tx on the client’s condition / well-being;
 whether the benefit outweighs the risk of harm; AND
 whether a different tx would be as beneficial.
 In the case of admission to a facility or a personal assistance service
 As assessment of the impact on the quality of the incapable’s life
Guiding principles in interpreting the legislation:
 Clients have legal & ethical right to info re their care & treatment, & a right to refuse that treatment.
 Whether/ø consent was obtaind by nurse, (s)he should always explain tx/prcdure they are performḡ
 Nurses should ø provide a tx if any doubt re if client understands & is capable of consenting.
o applies if/ø there is an order, or even if the client has already consented.
o does ø apply if SDM has consented.
 A SDM has the right to access the same info that a capable client would be able to access.
 Consent can be withdrawn at any time.
 Nurses need to advcate for clients' access to info re care & tx if it is ø forthcomḡ frm other care prvdrs
 Informed consent does not always need to be written, but can be oral or implied.
E. Working with Unregulated Care Providers
 ø assume a UCP competent to perform any procedure, regardless of how straightforward it appears
o must determine appropriateness in each clnt situatn̄  ensure measures are in place to promote the UCP’s
continuing competence.
 Expectations for nurses who work with UCPs
o A nurse who teaches, assigns duties to or supervises UCPs must:
 know UCP is competent to perform particular procedure / activity safely for the clt in the given circs.
 When teaching a UCP, a nurse is expected to have first-hand knowledge of the UCP’s competence.
 A nurse who assigns / supervises is expected to verify that UCP’s competence has been determined.
 ensure that the UCP:
 understands the extent of her or his responsibilities in performing the procedure(s
 knows when and who to ask for assistance, AND
 knows when, how and to whom to report the outcome of the procedure.
 ensure that there is an ongoing assessment of the client’s health care needs, develop a plan of care, evaluate
the client’s condition and judge the ongoing effectiveness of the UCP’s interventions.
o Nurses who delegate to UCPs must do so in accordance with regulation, see authorizing mechs
o When the employer and/or nurse are determining appropriate tasks for a UCP, they should assess:
 each client’s situation and condition
 the activity and associated risk, and
 the environmental supports.
 Controlled acts and expectations
o UCP onlyu has authority to perform a controlled act through an exception or delegation
 Regulated Health Professions Act, 1991 identifies the exceptions which include:
1. treatḡ a member of her/his household, & the procedure falls w/i the 2nd (substance by
injection/inhalation) or 3rd (putting an instrument/and/finger) controlled acts authorized to nursing,
2. assisting a person with routine activities of living, and the procedure falls within the second or third
controlled acts authorized to nursing (see the table below).
A procedure is considered to be a routine activity of living when its need, response and outcome have been
established over time and are predictable.
 Teaching, Delegating, Assigning and Supervising
o Teaching
 involves providing instruction and determining that a UCP is competent to perform a procedure.
o When is teaching required?
o Requirements for teaching
 may teach a controlled act procedure to a UCP when nurse meets all of the following reqs:
 Req 1: nurse has the knowledge, skill and judgment to perform the procedure competently.
 Req 2: nurse has the additional knowledge, skill and judgment to teach the procedure.
 Req 3: nurse accepts sole accountability for the decisn̄ to teach the procedure after considering:
o the known risks and benefits to the client of performing the procedure
o the predictability of the outcomes of performing the procedure
o the safeguards and resources available in the situation, and
o other factors specific to the client or setting.
 Req 4: nurse has determined that the UCP has acquired, through teaching and supervision of practice,
the knowledge, skill and judgment to perform the procedure.
 Req 5: nurse may teach the procedure to a UCP to perform for > 1 clt if has determined that the factors
in Reqs 3 & 4 are conducive to performing the procedure for >1 clt.
 Req 6: Considering the factors in Reqs 3 & 4, nurse evaluates the continuḡ competence of the UCP to
perform the procedure or reasonably believes that a mechanism is in place to determine the
UCP’s continuing competence.
 If the nurse is also delegating the controlled act to the UCP, see “delegation” below and the Authorizing
Mechanisms practice guideline for additional reqs that the nurse must meet.
o Delegation
 Transfer of authority to perform a controlled act procedure
o When is Delegation required?
o Assigning
 the act of determining or allocating responsibility for particular aspects of care to another
 includes assigning procedures that may or may not be a controlled act
 nurses with the necessary knowledge and judgment may assign care to a UCP
o Supervising
 monitoring and directing of specific activities of UCPs.
 It does not include ongoing managerial responsibilities.
 Supervision can be direct or indirect, depending on the circumstances.
o direct supervision: supervisor is physically present during the provision of care.
o indirect supervision: supervisor ø physically present but monitors activities by havḡ the UCP report
regularly to the supervisor, or by periodically observing the UCP’s activities.
o Expectations for Nurses Who Work With UCPs
F. Telepractice
 What is Nursing Telepractice?
o Delivery, mangm’t &coordinatn̄ of care & services provided via info & telecommunictn̄ technologies
 telephone and cell phone communication;
 email;
 video and audio conferencing;
 instant messaging (e.g., texting, multimedia, online chat);
 teleradiology
 telerobotics
o Examples of nursing telepractice include the following:
 answering questions about laboratory tests;
 providing disease-specific information, education, counselling and/or linking to resources
 e.g., hotline services, poison control centres, /phone lines for teenagers/mental health crisis intervention);
 facilitating audio &/or video consultations between health care provider (HCP) & pt / among HCPs;
 providing immunization assessment and counselling;
 assisting travellers to obtain health care at their destinations;
 providing health information &/or answering patient questions that promote patient self-care;
 using video, computer & data equipment to monitor the condition/health status of pts in their homes;
 sending camera images of a skin lesion to a dermatologist at a distant site; AND
 assisting with surgery on a patient at a distant site.
 Principles of Nursing Telepractice
1. The Therapeutic nurse-patient relationship
 Strategies to reduce the risk or missing important information
o Open-ended questions
o Questions in a logical sequence (c̄ attention & sensitivity to the pt’s acuity level
o finding solutions to communication, and language or cultural barriers;
o avoiding medical or technical jargon;
o avoiding premature conclusions regarding the patient’s situations or problems;
o listening & watching for verbal, emotional & behavioural cues that can convey important pt info
 e.g., body language, tone of voice, background noise;
o exploring a patient’s self-diagnosis
 e.g., says chest pain is just indigestion – questioning  other symptoms & medical hx suggest MI;
o avoiding second-guessing the patient
 e.g., if telephone caller requests ambulance, avoid suggesting that he/she drive to ER; AND/OR
o consulting c̄ & referring to appropriate HCPs when pt’s needs exceed knowledge, skill and judgment.
2. Providing and documenting care
 may use computer-based protocols, algorithms, standardized interview or other decision support tools.
o In cases in which a nurse’s judgment conflicts with the protocol and the nurse actively decides to override
the protocol, then the nurse is accountable for her/his decision and subsequent actions.
 When ø access to pt’s health record, another consistent method of collectḡ & recordḡ info must be found
o e.g., telephone log
 Nurses’ documentation of provider-to-provider interactions is expected to include:
o date and time of the interaction;
o name of the providers involved;
o name of the patient being discussed (when applicable);
o reason for the interaction;
o information provided/received;
o patient information provided/received;
o advice or information given/received;
o any follow-up required/provided;
o any agreement/consensus about the plan of care; AND
o the documenting nurse’s signature & designation.
 NOTE: different jurisdictions have different legislated documentation and storage requirements
3. Roles and responsibilities
 lack of face-to-face contact & reliance on technology to relay accurate & comprehensive info  risks
o to reduce risks, consider 3 decision-making factors when determinḡ most appropriate care provider: 1.
the nurse’s knowledge and skill
 RNs are expected to carry out a broader, more in-depth assessment and to analyze and synthesize
patient data to a greater extent than RPNs.
2. the patient
 The more complex the patient care requirements, the greater the need for the more in-depth
nursing competencies and skills provided by RNs.
3. the environment
 Supportive & stable environment includes, clear and identified practice support tools, systems in
place for consultation, a low patient turnover and a low proportion of novice staff.
 Examples of environmental supports include the following:
o policies, procedures and/or protocols;
o algorithms or other decision-support tools;
o standard assessment interview tools or guidelines and computer-based protocols; and
o the availability of expert, more experienced nurses
4. Consent, privacy and confidentiality
 Informed consent required < assessment & tx delivered by telepractice & includes telling the patient:
o nurse’s name, title, class of registration & jurisdiction of registration if practicing in another jurisdiction;
o nature of the help the nurse will give
 e.g., “I will ask you questions and then provide some information or advice.”;
o how to obtain more information or get further questions answered; AND
o whether the call is being recorded for quality monitoring purposes, either
 by telling the caller directly,
 providing printed notice OR
 having a recorded message that the caller hears before speaking with a nurse.
 standards of practice and legislation re privacy & confidentiality
o Personal Health Information Protection Act, 2004 (PHIPA) or
o CNO’s Confidentiality and Privacy — Personal Health Information practice standard
 Nurses demonstrate regard for privacy and confidentiality of a patient’s personal health info (PHI) by:
o informing pt that other health care team members directly involved in care will have access to PHI;
o informing pt when other health care team members are viewḡ or listeng ̑ to a telepractice interactn̄ ;
o obtaining the patient’s consent prior to reporting his/her name as a victim of abuse; AND
o informing the patient of the purpose for permanently retaining a record of a telepractice interaction
 e.g., for teaching
o Written consent for videoconference encounters is recommended by the telepractice industry [National
Initiative for Telehealth Guidelines (NIFTE), 2003].
o pt’s consent for collection, use & disclosure of PHI may be implied in certain telepractice encounters
 e.g., providing telephone advice
 Implied consent for sharing information among health care team members applies provided the
patients are advised of the health information practices.
 important to ensure that the environment, audio & visual interactions and images, and data are secure.
o To help ensure patient privacy:
 reasonable steps to ensure both ends of telecommunication links are secure
 e.g., asking the receiver if their fax machine is in a private area;
 take steps to ensure that passersby, casual intruders and unauthorized personnel are not present in
the area where audio or visual images are received;
 use your cellphone in the privacy of your vehicle;
 use first names or code numbers when discussing care;
 use the phone in a public area to only disclose general information;
 reserve the transfer of patient-specific information for face-to-face interactions;
 advocate for ø locatḡ voice & image-receivḡ tchnlgy (eg laptops/screens/monitors) in open areas;
 advocate for secure storage and handling of any retained video images;
 advocate for systems resources for the physical security of information.
 Patients should be made aware that e-mail messages will be kept in their health record (McFadden, 2002),
and that sites vary in the degree of encryption and other means of keeping data secure.
o Email is not always instantaneous - can arrive hrs/days later  ø use if immediate health concern
5. Ethical and legal considerations
 Nurses may want to ask their employers and/or professional associations about liability issues
o e.g., provisions for legal counsel, policies and procedures regarding liability, and whether an employer
advises or requires nurses to purchase malpractice insurance.
 Cases have been reported in other jurisdictions where nurses who provided telehealth advice
were accused of, or in some cases found liable for, professional misconduct for giving inappropriate or
inadequate advice (Castledine, 2003; Hall, 2003).
6. competencies
 Safe, efficient & ethical care in providing telepractice care if competencies in areas such as:
o critical thinking,
o the use of evidenced-based information,
o expert teaching, counselling, communication, interpersonal skills and
o the use of telepractice technology.
 Maintaining a Quality Practice Setting
o CNO encourages practice settings to incorporate the following strategies to develop and maintain a quality
practice setting that helps promote safe, effective and ethical care when nursing is provided using telepractice
technology.
Care delivery processes
 Supportḡ approp. use of nurses’ critical thinkḡ skills & clinical jdgm’t to vary frm estblshd protocls
 Supporting nurses in individualizing pt care.
 Facilitatḡ pt f/u activities as deemd apprprte by nurse, incl. referrls, consultatn̄ s & rtrn phone calls
 Workḡ c̄ nurses to provide evidence-based protocols, guides and documentation tools
 to facilitate interviewing, decision-making about advice and disposition.
 Supporting regular updating of clinical protocols & guidelines appropriate for pt population.
 Providing sufficient staff resources to enable best nursing practices.
 Providing staff with access to interpreters.
Leadership
 Establishing and maintaining interdisciplinary quality review processes that address
 patient safety issues AND
 variances from standardized assessment guides or protocols.
 Ensuring that required changes to guides and protocols are made based on best evidence.
 Establishing a process whereby nurses may raise concerns & work with managers to
 resolve issues related to workload management or
 resolve issues related inappropriate workplace pressures
o e.g., pressure to divert patients away from emergency departments.
 Ensuring that nurses have the available resources,
 eg secure telecommunication facilities & equipm’t, when providḡ telepractice interventions
 Ensuring that nurses have systems to document information
 in a safe, secure manner AND
 in a way that is easily accessible and centralized.
Organizational supports
 Providing supportive policy related to expectations of a nurse’s role in telepractice.
 Establishḡ positn̄ dscrptn̄ s clearly articulatḡ roles & rspnsblts of nrss engagd in telepractice
(NIFTE, 2003, p. 10).
 Prvidḡ staff c̄ current resources/links to enable coordinatn̄ of services to meet pt needs effectively.
 Supporting an adequate length of time for each nurse-patient telephone interaction.
 Adopting workload measures that take into account time spent on all telepractice activities.
 Providing safe, reliable and up-to-date technology, and timely technology support.
 Providḡ for staff needs related to areas such as ergonomics, lightḡ, noise reductn̄ & work breaks.
Communication systems
 Providḡ paper-/computer-based form/log for docum’tatn̄ of teleprctce pt intractn̄ s if chart ø avail
 A log may be used in settings where pt chart is inaccessible to nurses upon pt’s discharge.
o Completed forms/log entries should be linked & entered into the pt health record so that the info is upto-date & centralized.
Professional development systems
 Providing nurses with relevant professional development opportunities related to the use of telepractice
technology and care delivery processes.
There are 4 case scenarios
G. Independent Practice
 nurses in independent practice as those who are:
o self-employed for the purpose of providing nursing services, and/or
o operating their own nursing business.
 incorporate c̄ the ON or CAN gov. or set up a Health Professional Corporation c̄ CNO
 Record Keeping
o Under PHIPA (Personal Health Information Protection Act, 2004)
 nurses who provide health care services may be considered health information custodian for records
associated with the nursing services they provide.
 If HI custodian, employees are your agents  must
o establish policies that are consistent with PHIPA requirements,
o educate your employees about these policies and
o put procedures in place to monitor their compliance with the policies.
o prudent to retain clts’ health rcrds of nrsḡ srvcs for min of 10 yr after nrs- clt rltn̄ shp is trmntd
 if the client is a minor, for a minimum of 10 years after the client’s 18th birthday.
o under provincial law, CNO has the authority to inspect nurses’ records and practice premises.
 may have to provide access to client/business records & practice premises when CNO is:
 conducting an investigation (to examine anything that is relevant to an investigation)
 administering the QA Program
 Fees and services
o Setting fee: consider fees comparable to that of other nurses and/or health care providers who have
similar competencies and experience, and who provide similar services.
o accountable for:
 informing clients in advance of your fees and acceptable methods of payment
 informing clients in advance of fees for missed appointments or late payments
 providḡ clts c̄ adequate notice < changḡ fees & informḡ in advnce of what notice period is
 providing clts with an official receipt listing the nursing services provided &products sold.
o Under provincial law the following activities are considered to be professional misconduct:
 submitting an account or charge for services, which is false or misleading
 failing to fulfil the terms of an agreement for professional services
 charging a fee that is excessive in relation to the services provided
 charging a fee to be available to provide services to a client
 offering or giving a reduction for prompt payment
 failing to itemize an account for professional services
 selling or transferring any debt owed to you for professional services.
 do not recommend or promote unnecessary services to clients.
 if your nursing practice involves direct interaction with individual clients, you should not:
o offer discounts or coupons for your services
o provide promotional offers
o charge fees in advance for a service you have not yet provided.
 If you provide group education sessions or consulting services to organizations,
o use your professional judgment to determine whether it is appropriate
 to offer discounts, coupons and promotions, and/
 or charge fees in advance for the nursing service you provide.
 Using, recommending, providing, or selling client-care products
o can create a conflict of interest for nurses  MUST
 identify &ethically manage potential conflict
 avoid situations when the nurse-client relationship could be used for personal benefit.
o Using = using during visit, recommending, providing free-of-charge, or selling for self-care
o When selecting products, use your professional judgment to consider the:
 best interests of the client
 best available evidence from appropriate and objective sources
 client’s individual needs and choices.
o When using, recommending, providing or selling products, you MUST:
 provide objctve, evidence-bsd hlth eductn̄ to clts re factors to consider when selectḡ a product
 discuss evidence-based options and other products if available.
o If you supply products for use in client care, you are accountable for:
 procuring the products from appropriate sources
 storing the products according to the manufacturers’ directions.
o If you use, provide or sell products to clients
 expected to keep records that will make it easy to track the products from the point of procurement to the
point of client care.
 In addition, you must avoid:
 using your professional designation to endorse a product
 benefitting from using, recommending, providing or selling products to clients, or
 advertising that you sell products to clients
o advertising = To make known to the general public (does not include communicating directly to an
existing client about professional services)
 Medication
o Any nurse may recommend / admin over-the counter medication to clients if law allows
 Public Hospitals Act required all tx including OTC meds to be ordered
o NPs  controlled act of prescribḡ, selling or compounding drugs in accordance c̄ regulations.
o Nurses in independent practice who provide nursing services to clients in facilities must confirm
whether they are authorized to administer medications or treatments to clients in that particular
setting, and what requirements may apply.
 To ensure safe client care and prevent inadvertent duplication, you must
o consider the coordination and continuity of care.
 For example, when providing services to clients in facilities, you should ensure that relevant
members of the health care team are given info that is NB for the client’s care plan, such as
services provided and client’s response.
 Professional liability protection
o expected to obtain in accordance with current regulatory requirements.
 Advertising
o The College maintains the public’s trust in the nursing profession by regulating nurses’
advertisements to ensure that the public is given relevant information and is not misled.
 When advertising your services to the public, you are accountable for:
 including a description of your services, to help clients make informed decisions
 including only accurate, factual and verifiable information
 providing evidence-based references to support statements
 including your name and protected title (RPN, RN or NP).
o If you have both RN and RPN certificates of registration:
 use the title that is consistent c̄ type of nursḡ services offered in the ad
o If you are self-employed and also practise nursing as an employee, you MUST
 avoid promoting your independent nursing services and/or
 recruiting clients from your employer’s practice setting.
o Your advertisements must not include:
 the College’s logo
 guarantees
 references to products that you use or sell
 comparative or superlative statements
 sensational claims.
o When your nursing practice involves direct interaction with individual clients, you MUST NOT
 include client testimonials in your advertising.
o If you provide group education sessions or consulting services to organizations,
 use profess. jdgm’t to detrmne if appropr to use unsolicitd clt testimonials in your advertisḡ
 It is never appropriate to solicit testimonials from clients
 Employees
o When you employ staff (regulated and/or unregulated), you MUST
 be familiar with the unique accountabilities associated with employing staff, including
 developing appropriate policies for staff and
 ensuring they are aware of the policies.
H. Refusing Assignments and Discontinuing Nursing Services
 Professional Standards, Revised 2002 – a nurse demonstrates accountability by:
o providing, facilitating, advocating and promoting the best possible care for clients;
o seeking assistance appropriately and in a timely manner;
o taking action in situations in which client safety and well-being are compromised; and
o maintaining competence and refraining from performing activities for which she/he is not competent.
 In addition, a nurse in an administrator role demonstrates accountability by:
 ensuring mechanisms allow for staffḡ decisn̄s in best interest of clts & professional practice; and
 advocatḡ for qulty prctce envrnm’t that supports nrss’ ability to provide safe, effective & ethical care
 Ethics
o Nurses demonstrate regard for client well-being and maintain commitments by:
 using their knowledge and skill to promote clients’ best interests in an empathetic manner;
 putting the needs and wishes of clients first;
 identifyḡ if own values & beliefs conflct c̄ ability to keep implicit & explicit promises & takḡ approp. actn̄ ;
 advocating for quality client care; and
 makḡ all reasonable efforts to ensure that clt safety & well-being are maintained during any job action.
 Legislation
o The Nursing Act, 1991 includes regulations that define professional misconduct.
 no specific definition of professional misconduct that includes the word abandonment,
 defs can guide re what might constitute prof mscndct if refusing an assignm’t or discont. Nrsḡ services.
o Each situation would be assessed on its own merit.
o relevant definitions of professional misconduct in the legislation are found in the following clauses.
1 (1) Contravening a standard of practice of the profession or failing to meet the standard of practice
of the profession
1 (4) Failing to inform the member’s employer of the member’s inability to accept specific
responsibility in areas where specific training is required or where the member is not
competent
1 (5) Discontinuing professional services that are needed unless:
i. the client requests the discontinuation,
ii. alternative or replacement services are arranged, or
iii. the client is given reasonable opportunity to arrange alternative or replacement services
1 (29) Failing to fulfil the terms of an agreement for professional services
1 (37) Engaging in conduct or performing an act relevant to the practice of nursing that having
regard to all the circumstances would reasonably be regarded by members as disgraceful,
dishonourable or unprofessional
 Refusing assignments
o 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.
 Discontinuing nursing services
o Abandonment occurs when a nurse has accepted an assignment 1 (5) conditions met
 could be found guilty of professional misconduct.
 Guidelines for Decision-Making
o Collaboration, respectful behaviour & collegial communication among everyone in the nursing and health team
contribute to positive outcomes for clients and prevent problems from arising in determining how nursing
services are to be delivered.
o important that nurses advocate for appropriate staff and for planning for work stoppages.
 Underlying principles – to guide decision when considering refusing an assignment or discontinuing services.
o The safety and well-being of the client is of primary concern.
o Critical appraisal of the factors in any situatn̄ is the foundatn̄ of clinical decisn̄-making & professional jdgm’t
o Nurses are accountable for their own actions & decisions and do not act solely on the direction of others.
o Nurses have the right to refuse assignments that they believe will subject them or their clients to an
unacceptable level of risk (College of Nurses of Ontario, 2003, p. 9).
o Nurses are not required to work extra shifts or overtime for which they are not contracted.
o Individual nurses and groups of nurses safeguard clients when planning and implementing any job action
(Canadian Nurses Association, 2002, p. 22).
o Persons whose safety requires ongoing or emergency nursing care are entitled to have these needs satisfied
throughout any job action (Canadian Nurses Association, 2002, p. 22).
 Key expectations – In choosing the appropriate course of action, nurses are expected to do the following.
o 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.
o Identify concerns that affect her/his ability to provide safe, effective care.
o Communicate effectively to resolve workplace issues.
o Become familiar with the collective agreement or employment contract relevant to her/his settings and take
this into account when making decisions.
o Learn about other legislation relevant to her/his practice setting.
o Give enough notice to employers so that client safety is not compromised.
o Provide essential services in the event of a strike.
o 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).
 Decision-making process
o includes 4 cyclical components & can begin at any point; best outcome requires consideration of all 4
1: Identify the issues, values, resources and conflicting obligations
1. a) Have you previously agreed to accept the shift/ assignment?
2. b) What are the conflicting obligations, beliefs and values?
3. c) What are your values and emotions as they relate to the situation?
Are they influencing your ability to think clearly?
4. d) Have you gathered the facts of the situation from credible sources?
5. e) How have similar situations been handled in the past and what were the implications?
Is there an organizational policy or relevant legislation in place?
6. f) How will the care of the clients be affected if you leave?
7. g) What are the specific nursing care needs and priorities of the clients?
2: Identify the options and develop a plan/ approach
1. a) Identify possible alternatives /solutions other than refusḡ the assignment/discontinuḡ a service.
Are other resources available (for example, protective equipment or expert resources)?
Can you ask the administrators for help?
2. b) Identify the risks & benefits for clients, nurses & others associated with each solution.
How can those risks be minimized?
3. c) Prioritize client care needs. Consult institutional policy/process, if available.
4. d) Identify all available resources & various optn̄s to ensure approp. staffḡ  essential clt care needs
Eg, stay for a short time beyond end of your shift/can someone come in early for the next shift?
5. e) Consider modifying existḡ plan of care temporarily so remainḡ staff can focus on essential care
needs, monitor the client(s) for changes in condition and act appropriately.
6. f) Weigh the options and decide on an approach.
7. g) Communicate to the appropriate person(s) the details of the problem and the planned solution.
3: Implement the plan
a) If you decide to leave, ensure remaining staff are aware of immediate & essential client care needs.
b) If you stay to provide care, monitor ongoḡ client care priorities & your own ability to practise safely.
c) Document (eg, in professional responsibility forms, incident reports or personal notes) your decision,
rationale and action taken. Include time, who you communicated with and actions taken to safeguard
the client(s).
 Keep a copy for yourself and give one to your employer and one to your risk manager.
d) Document the care provided and any unmet client needs on the client record.
Communicate outstanding care needs to the appropriate person.
e) When floating to other practice areas, agree to provide only aspects of care for which you are
competent (for example, vital signs, medication administration).
4: Review, discuss and evaluate the process
a) When the immediate crisis is over, review the effectiveness of the decision/action (for example, the
outcomes).
b) Collaborate to plan strategies to prevent and/or manage similar situations in the future.
c) Develop strategies to solve ongoing safety issues. Strategies may involve literature reviews, advocacy,
etc.
d) Express ongoing concerns about staffing from the perspective of the impact on client care and safety.
 Maintaining a Quality Practice Setting
o Care Delivery processes
o Leadership
o Organizational supports
o Communication
o Complaints about Nurses’ Practice
There are 3 scenarios
I. Conflict Prevention and Management
 In this doc, conflict = a power struggle in which a person intends to harass, neutralize, injure / eliminate a rival.
o Conflict that is managed effectively by nurses can lead to personal and organizational growth.
o conflict ø managed effectively can hinder ability to provide quality client care & escalate into violence & abuse.
 Abuse = misuse of power within a relationship. (emotional, verbal, physical and/or sexual)
 Eg abusive behaviours include intimidation, swearing, cultural slurs, hitting, pushing, inappropriate
comments, inappropriate touching and sexual assault.
 the provision of professional services to clients does not include accepting abuse.
o conflict among colleagues can lead to antagonistic and passive-aggressive behaviours (such as bullying or
horizontal violence) that compromise the therapeutic nurse-client relationship.
 Horizontal violence = Interpersonal conflict among colleagues that includes antagonistic behaviour such as
gossiping, criticism, innuendo, scapegoating, undermining, intimidation, passive
aggression, withholding information, insubordination, bullying, and verbal and physical
aggression.
 Nurse-Client Conflict
o Key factors
 Conflict between a nurse and a client can escalate if a client is:
a) intoxicated or withdrawing from a substance- induced state;
b) being constrained (for example, not being permitted to smoke) or restrained (for example, with a physical
or chemical restraint);
c) fatigued or overstimulated; and/or
d) tense, anxious, worried, confused, disoriented or afraid.
 Conflict between a nurse and a client can escalate if a client has:
a) a history of aggressive or violent behaviour, or is acting aggressively or violently
(for example, using profane language or assuming an intimidating physical stance);
b) a medical or psychiatric condition that causes impaired judgment or an altered cognitive status;
c) an active drug or alcohol dependency or addiction;
d) difficulty communicating (for example, has aphasia or a language barrier exists); and/or
e) ineffective coping skills or an inadequate support network.
 Conflict between a nurse and a client can escalate if a nurse:
a) judges, labels or misunderstands a client;
b) uses a threatening tone of voice or body language (for example, speaks loudly or stands too close);
c) has expectations based on incorrect perceptions of cultural or other differences;
d) does not listen to, understand or respect a client’s values, opinions, needs and ethnocultural beliefs;
e) does not listen to the concerns of the family and significant others, and/or act on those concerns when it is
appropriate and consistent with the client’s wishes;
f) does not provide sufficient health information to satisfy the client or the client’s family; and/or
g) does not reflect on the impact of her/his behaviour and values on the client.
o Prevention
 employ client-centred care strategies to prevent behaviours that contribute to the escalation of conflict.
 Nurses can:
a) continually seek to understand the client’s health care needs and perspectives;
b) acknowledge the feelings behind the client’s behaviour;
c) ask open-ended questions to establish the underlying meaning of the client’s behaviour;
d) engage in active listening (eg, use verbal and nonverbal cues to acknowledge what is being said);
e) use open body language to display a calm, respectful and attentive attitude;
f) acknowledge the client’s concerns about the health care system and his/her experiences as a client;
g) respect and address the client’s wishes, concerns, values, priorities and point of view;
h) anticipate conflict in situatn̄ s in which it has previously existd & create a plan of care to prevent its escalatn̄ ;
i) reflect to understand how her/his behaviour and values may negatively affect the client.
 Conflict With Colleagues
o Key factors
 Conflict among colleagues can escalate if:
a) bullying or horizontal violence exists;
b) barriers to collaborative collegial behaviour encourage the marginalization of others
(for example, formation of identity groups based on culture or religion);
c) different practice perspectives are accentuated by factors such as age, length of service, generation gap,
culture and education level;
d) team members do not support each other in achieving work responsibilities or meeting learning needs;
e) colleagues are intentionally or unintentionally put into situations beyond their capabilities;
f) new graduates &/ employees are not supported by experienced nurses &/ systemic orientation practices;
g) fear of reprisal impedes the reporting of conflict by staff; and/or
h) there is a lack of awareness about the need to anticipate and manage conflict.
o Prevention
 Nurses are less likely to be abused by clients if they do not tolerate abuse among colleagues.
 strategies to help prevent conflict among colleagues from escalating – Nurses can:
a) promote a respectful work environment by modelling professional behaviours;
b) mentor, support and integrate new staff members into the practice setting;
c) reflect on personal attitudes, motivators, values and beliefs that affect relationships with colleagues,
identify personal areas in need of improvement and strive to alter their own behaviour in situations that
have previously ended in conflict; and
d) recognize that personal stress may affect professional relationships and take steps to manage that stress.
o Management
 Positive collegial relationships result from good communication, mutual acceptance and understanding, use of
persuasion rather than coercion, and a balance of reason and emotion when working with others.
 Nurses can:
a) address conflict directly rather than avoiding or postponing its resolution;
b) focus on the behaviours that lead to the conflict rather than on the colleague personally;
c) validate assumptions through open dialogue c̄ colleagues rather than acting on misperceptn̄s/assumptin̄ s;
d) collaborate with colleagues to identify the underlying cause of the conflict.
 In some situations, a neutral party (for example, a professional mediator) may be necessary.
 Workplace Conflict
o Key factors
 A quality work environment is one that supports nurses in preventing and managing conflict in daily practice.
 This support includes the reduction or elimination of workplace factors that can lead to conflict.
 Conflict can escalate if:
a) organizational policies or programs aimed at identifying, preventing and managing
the incidence of conflict and abuse in the workplace do not incorporate and address prohibited grounds
under the Human Rights Code, such as race, ethnicity or sexual orientation;
b) organizational policies are not communicated to staff or adhered to at all levels;
c) there is a lack of formal performance feedback mechanisms;
d) existing formal performance feedback mechanisms do not address how behaviours affect conflict;
e) the workplace culture promotes under-reporting of incidences of conflict;
f) managers and administrators abuse or bully;
g) managers & administrators show favouritism to certain staff members & ignore their disruptive behaviour;
h) there is a lack of role clarity for staff;
i) communication is negatively affected by working conditions (eg, heavy workload or fast work pace);
j) nurses and other health care professionals are working at peak stress times or under stressful conditions;
k) working conditions are poor (eg, lack of ventilation, too much noise, safety hazards);
l) intense organizational change exists; and/or
m) staff perceive job insecurity.
o Prevention
 In a quality work environment, employers provide mechanisms that nurses can readily use to intervene in
conflict before it escalates.
 Employers can:
a) implement policies that do not tolerate abuse of any kind;
b) ensure that policies against workplace conflict are also directed at combating any form of discrimination;
c) ensure that managers model professionalism in preventing and managing conflict;
d) establish & uphold orgnztional values, visn̄ & missn̄ that acknowledge health, safety & well-being of staff;
e) educate managers and staff in communication, as well as in conflict prevention and management;
f) support effective collaboration and communication among health care team members, especially between
nurses and physicians34 (for example, interprofessional rounds);
g) implement strategies to ease the impact of change and decrease stress among staff;
h) identify and address staffing needs as soon as possible, especially at peak times; and
i) ensure a comfortable and safe physical environment (eg, use safety mirrors, security guards, protective
barriers, surveillance cameras and/or a system of alert when urgent help is needed).
o Management
 Employers can institute reporting systems to help nurses acknowledge when conflict has occurred.
 A fair and efficient reporting system encourages communication among staff members by helping nurses
identify underlying causes of conflict.
 Open communication and understanding will promote an atmosphere of trust and respect within the
health care team.
 Employers can:
a) provide a system that:
i. promotes the reporting of incidences of workplace conflict,
ii. protects nurses from reprisal and
iii. deals with reports fairly and efficiently;
b) routinely assess the incidence of workplace conflict and implement strategies for corrective action; and
c) institute clear policies & consequences for those who breach policies aimed at preventḡ conflict & abuse.
 Role of Nurses in Formal Leadership Positions
o Nurses in formal leadership positions are responsible for supporting nurses in effective conflict management.
 Eg, nurse administrators should establish systems that facilitate the development of conflict-resolution skills
for all members of the health care team.
o Preventing conflict among staff members
 Nurses in formal leadership positions can:
a) make conflict resolution a priority among all staff members;
b) empower staff members to resolve problems among colleagues;
c) provide nurses with greater autonomy by participating in decision-making and opportunities for
professional development;
d) foster positive relationships, trust and respect among staff members and promote a work environment in
which conflict-creating forms of behaviour (for example, exclusion or dysfunctional cliques) are not
tolerated;
e) recognize the factors that contribute to conflict and promptly intervene to diffuse conflict situations before
they escalate;
f) help staff members to develop conflict- management interventions;
g) recognize that change can precipitate conflict and implement management strategies that encourage
positive attitudes toward change; and
h) seek learning opportunities to increase the comfort level of staff members in dealing with conflict
resolution.
o Managing conflict among staff members
 Nurses in formal leadership positions can promote conflict management among staff by:
 establishing and using reporting processes that are fair and confidential
 actively resolving conflict among staff
 Nurses in formal leadership positions can:
a) offer a confidential environment for staff to report episodes of conflict without fear of retribution;
b) deal with reports promptly, fairly and confidentially; and
c) ensure that appropriate follow-up procedures are in place to support nurses who have been abused in the
course of their practice.
o Debriefing After a Critical Incident
 Debriefing allows nurses to reflect on and learn from what has occurred - can provide insight into the conflict’s
contributing factors, as well as contribute to its future prevention and management.
 Nurses can:
a) consult with those involved about the meaning of their experiences during the incident with the intent to
heal themselves and the client and family;
b) review and reflect on responses and recommend future strategies based on team members’ actions;
c) reflect on their own behaviour, which may have unintentionally affected the nurse-client relationship;
d) help client understand how his/her behaviour negatively affected the therapeutic nurse-client relationship;
e) develop communication strategies with the client so the client can express his/her feelings appropriately;
f) use best-practice strategies to develop a care plan for dealing with the client’s behaviour; and
g) use anticipatory planning to develop a consistent approach of addressing client’s behaviour in the future.
 Anticipatory planning = Involving client in making decisions based on the client’s values, beliefs & wishes