self-study guide to the code of ethics and other legal and ethical considerations for quebec nurses

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1 self-study guide to the code of ethics and other legal and ethical considerations for quebec nurses

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3 Note February, 2016 Appendix I Code of Ethics of Nurses Since the publication of the Self-Study Guide, a new version of the Code of Ethics of Nurses has come into effect, on October 22, Although the Guide has not been updated, the information it contains remains current and valid. Of the sections of the Code referred to in the Self-Study Guide, only sections 18 and 45 have been amended in the new Code of Ethics of Nurses (sections quoted on pages 24, 26 and 42 of the Guide). Section 18: A nurse shall keep her or his professional knowledge and skills up to date in order to provide care and treatment in accordance with generally accepted standards of practice. A nurse shall practise her or his profession in accordance with generally accepted standards of practice and scientific principles. To that end, she or he shall update and develop her or his professional knowledge and skills. Section 45: A nurse shall not be negligent when administering medication administering or adjusting medication or other substances. In particular, when administering medication or other substances, a nurse shall have sufficient knowledge of the medication and abide by the principles and methods applicable to its administration. Appendix II Relevant Sections of Acts and the Regulation As for the acts and regulations in Appendix II, only section 15 of the Civil Code of Québec has been amended since the Self-Study Guide was published (section quoted on page 150 of the Guide). Section 15: Where it is ascertained that a person of full age is incapable of giving consent to care required by his or her state of health and in the absence of advance medical directives, consent is given by his or her mandatary, tutor or curator. If the person of full age is not so represented, consent is given by his or her married, civil union or de facto spouse or, if the person has no spouse or his or her spouse is prevented from giving consent, it is given by a close relative or a person who shows a special interest in the person of full age.

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5 self-study guide to the code of ethics and other legal and ethical considerations for quebec nurses An English version of the guide has been produced by the OIIQ in this case, to help nurses educated outside Quebec better prepare for the entry-to-practice examination and integrate more easily into the Quebec context. The Order wishes to remind you, however, that in accordance with the Charter of the French Language, permits may be issued only to those candidates who have sufficient knowledge of French to practise the profession. Otherwise, they must obtain an attestation from the Office québécois de la langue française (OQLF) before the OIIQ can issue a permit.

6 Production Publications Department Sylvie Couture Department Head Karine Méthot Production Assistant Claire Demers Publishing Assistant Member Services and Communications Department, OIIQ Graphic design and production Translation Les traductions Terry Knowles Inc. Revision Teresa Berghello, Lyne de Palma and Susan Young Nursing program coordinators, John Abbott College Proofreading Les traductions Terry Knowles Inc. Distribution Publication Sales Ordre des infirmières et infirmiers du Québec 4200 Dorchester Boulevard West Westmount, Quebec H3Z 1V4 Tel.: (514) or Fax: (514) ventepublications@oiiq.org Legal deposit Library and Archives Canada, 2010 Bibliothèque et Archives nationales du Québec, 2010 ISBN Ordre des infirmières et infirmiers du Québec, 2010 All rights reserved Note - In keeping with OIIQ editorial policy, the feminine gender has been used to simplify the text. No discrimination is intended.

7 Project Managers Judith Leprohon, RN, PhD, Scientific Director, OIIQ Sylvie Truchon, RN, MSc, Syndic, OIIQ Co-ordination and texts Nicole Roger, RN, MSc Contributors Contribution to texts and validation of specialized content Professional ethics Sylvie Truchon, RN, MSc, Syndic Ethics Marcelle Monette, RN, PhD, consultant Legal considerations Marie Paré, Attorney, consultant Validation Internal validation Martine Dubé, RN, Master s candidate, Law and Health Policy, Assistant Syndic, OIIQ Suzanne Durand, RN, MSc, Graduate Certificate in Bioethics, Director Professional Development and Support Department, OIIQ Monique Flibotte, RN, MSc, Nursing Consultant, Traineeship and Equivalence Admission, Registrar s Office, OIIQ Carole Mercier, RN, MSc, Secretary General, OIIQ Nancy Lévesque, RN, Graduate Certificate in Nursing, Assistant Syndic, OIIQ External validation Two groups of nursing graduates from outside Quebec helped validate this guide the first validated the prototype to test the educational approach and the second validated the final document. These nurses were from Brazil, Ivory Coast, Haiti, Lebanon and Romania. Consultation When we started work on this guide, a group of nurses responsible for professional integration of nursing graduates from outside Quebec, at college and in clinical settings, helped identify the situations presenting the most difficulty for these nurses with regard to the Code of Ethics of Nurses and other legal and ethical considerations as they apply to nursing in Quebec. Acknowledgments We wish to thank the Ministère de l Immigration et des Communautés culturelles for its financial assistance toward the production of this guide and the three nursing program coordinators from John Abbott College for their contribution for the revision of the English version of the document.

8 table of contents Preamble 7 Section 1 The Code of Ethics of Nurses...9 Overview of the Code of Ethics Fundamentals Regulation An overview of the contents of the Code Reading EXERCISE 1.1 Identifying and applying sections of the Code of Ethics of Nurses Answer guide EXERCISE 1.2 Determining the appropriate professional conduct in situations involving issues related to the Code of Ethics Answer guide The Professional Relationship Fundamentals Nature of the professional relationship Boundaries of the professional relationship Reading EXERCISE 1.3 Determining the nature and boundaries of the professional relationship Answer guide EXERCISE 1.4 Determining the appropriate professional conduct in situations relating to the professional relationship Answer guide Professional Independence and Conflicts of Interest Fundamentals Professional independence EXERCISE 1.5 Recognizing the elements of professional independence Answer guide

9 Fundamentals Conflict of interest Reading EXERCISE 1.6 Recognizing a conflict of interest Answer guide EXERCISE 1.7 Determining the appropriate professional conduct in situations where there is a risk of a conflict of interest Answer guide Section 2 Other Legal Considerations for Quebec Nurses Fundamentals Legislative framework governing nursing in Quebec Clients rights with respect to health care Nurses professional liability Reading EXERCISE 2.1 Identifying and applying acts and regulations Answer guide Section 3 Other Ethical Considerations for Quebec Nurses Fundamentals Ethics Personal and professional values Definitions of values EXERCISE 3.1 Determining values Answer guide EXERCISE 3.2 Recognizing conflicting values EXERCISE 3.3 Answer guide Determining the appropriate professional conduct in situations involving ethical issues Answer guide Table of Contents 5

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11 preamble The purpose of this self-study guide is to simplify the professional integration of Internationally Educated Nurses (IEN), by familiarizing them with the Code of Ethics of Nurses and other legal and ethical considerations relating to nursing in Quebec. Produced with the financial support of the Ministère de l Immigration et des Communautés culturelles, it is designed to help IENs understand the links between these important dimensions of nursing along with the role of Quebec nurses, in particular with regard to their professional independence. The teaching approach used in this guide will allow these nurses to apply the main principles governing these specific aspects of the nursing profession in Quebec, and to gradually integrate the underlying knowledge through a variety of role-playing exercises. This educational guide may also be useful for Quebec nursing students, to help them learn these principles and apply them in their professional practice. The guide is divided into three sections. The first covers the Code of Ethics of Nurses and looks more specifically at the professional relationship and professional independence and conflicts of interest. The second part deals with other legal considerations, with an emphasis on clients rights and nurses professional liability. Lastly, the third section addresses other ethical considerations and takes an overall approach, so that readers can make decisions on their professional conduct in different situations in light of the applicable factors relating to the law and professional ethics. Preamble 7

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13 Section 1 the Code of ethics of Nurses This three part section looks at the Code of Ethics of Nurses as it applies to nursing in Quebec. The first part presents an overview of the Code of Ethics of Nurses. The second and third parts deal with specific ethical aspects concerning the professional relationship and professional independence and conflicts of interest. These aspects were chosen because they are more likely to give rise to questions on the part of nurses from outside Quebec. Each part also includes role playing exercises in which you are asked to identify and apply the relevant sections of the Code of Ethics of Nurses and to determine the appropriate professional conduct in the circumstances.

14 Overview of the code of ethics Fundamentals regulation The Code of Ethics of Nurses essentially refers to all the duties and moral obli gations specific to a profession, which guide professionals in their everyday relations with the public, clients and other professionals, from the point of view of professional and individual responsibility. The code of ethics is a keystone of professional legislation in Quebec, setting out the duties and obligations specific to a profession. A code of ethics explains how the members of a profession are to conduct themselves in order to protect the public. Although it lays out the profession s ethical ideals, the Code of Ethics of Nurses is first and foremost a regulation. The standards it defines are considered min imal, meaning that they are a basic threshold. Consequently, any violation of these professional duties and obligations compromises public protection and can result in sanctions being imposed by the Order s Disciplinary Council. The Code presents basic guidelines for nurses in their daily practice. The way in which they are applied will always depend on the nurse s judgment and the context. Section 1 To help nurses understand and apply the sections of the Code, the OIIQ Web site has a section devoted to it. Aside from the Code itself, nurses may wish to consult the Ethics Update column by the Syndic in each issue of The Journal, looking at ethical issues specific to the profession _Sec1_ALDO-EN_2851_F.indd 10 1/12/10 10:43:31 AM

15 An overview of the contents of the Code The Code of Ethics of Nurses comprises two chapters. The first deals with duties toward the public, clients and the profession. It is broken up into 10 divisions, some of which are further subdivided. All in all, this chapter comprises 81 sections dealing with different aspects of the nursing profession. Chapter II presents the final provisions. Division I Duties inherent to the practice of the profession General provisions Integrity Condition liable to impair the quality of care and services Competence Professional independence and conflict of interest Availability and diligence This division, in addition to general provisions, deals with nurses integrity and competence, their availability and the diligence they must display in practising the profession. In addition, a subdivision is devoted to nurses duties and obligations concerning professional independence and conflicts of interest. It also looks at the importance for nurses to practice in a condition that does not impair the quality of care and services. Division II Relationship between the nurse and the client Relationship of trust Secrecy of confidential information Prohibited behaviour This division sets out nurses professional duties and obligations concerning the relationship of trust to be established with the client, and steps to be taken to preserve the secrecy of confidential information. It also outlines prohibited behaviour so as to preserve the professional relationship. Division III Quality of care and services Information and consent The therapeutic process The division on the quality of care and services sets out nurses duties and obligations related to information to be given to the client and consent to care, and to the therapeutic process. The Code of Ethics of Nurses 11

16 Division IV Division V Division VI Relations with persons with whom the nurse interacts in the practice of the profession Relations with the Order Determination and payment of fees These three divisions of the Code deal with nurses relations with the OIIQ and with other individuals in the practice of the profession. Rules are also laid out regarding the determination and payment of fees charged by nurses in private practice. Division VII Conditions and procedures for the exercise of the client s rights of access and correction of information contained in records established in respect of him or her Client s access to his record Correction of information in the client s record Release of documents to the client This division describes under what circumstances and how a client may exercise his right to see and correct information contained in any records established in respect of him, whether the nurse practises in the public or private sector. Division VIII Division IX Division X Conditions, obligations and prohibitions relating to advertising Professions, trades, industries, businesses, offices or duties incompatible with the dignity or practice of the profession graphic symbol of the Order Divisions VIII and X describe rules relating to advertising aimed at the public and the use of the graphic symbol of the OIIQ. Division IX identifies exceptional cases in which a nurse may sell products or vaccines. Section 1 12

17 Reading At this point, we suggest that you read the divisions of the Code of Ethics of Nurses (Appendix I), to familiarize yourself with its structure and to be able to identify the relevant sections of the Code in the following exercises. Identifying and applying sections of the Code of Ethics of Nurses Exercise 1.1 In this exercise you are asked to identify the relevant sections of the Code of Ethics of Nurses and apply them in each of the situations described. To check your answers and comments, see the answer guide on page 24. Applying the sections of the Code to actual situations faced by Quebec nurses will help you understand how the ethical duties and obligations laid out in the Code are to guide you in your practice. The Code of Ethics of Nurses 13

18 The head nurse asks you to take part in training, during your working hours, on a new device that will be used in your unit. You wonder whether you are required to attend this training, which you consider an extra task. Situation What would you do? Would you attend the training or not? What section(s) of Division I of the Code of Ethics can guide you in your decision? Given your ethical duties and obligations, if this situation occurred in your practice, would you make the same decision? If not, please explain. Section 1 14

19 You are working the night shift, and you haven t been able to sleep for two days. One of your clients has a prescription for Ativan as required. You wonder whether you can take an Ativan tablet and mark it down with the client s name. Situation What would you do? Take the client s Ativan or not? What section(s) of Division I of the Code of Ethics can guide you in your decision? Given your ethical duties and obligations, if this situation occurred in your practice, would you make the same decision? If not, please explain. The Code of Ethics of Nurses 15

20 You are caring for an elderly client who has trouble communicating. Members of his family, who are constantly at his bedside, complain that his dressing hasn t been changed yet. You are completely overwhelmed with work. You try unsuccessfully to explain the situation to the family, and you can feel your patience wearing thin. You wonder whether you should ask a colleague to intervene. Situation What would you do? Would you ask your colleague to intervene or not? What section(s) of Division II of the Code of Ethics can guide you in your decision? Given your ethical duties and obligations, if this situation occurred in your practice, would you make the same decision? If not, please explain. Section 1 16

21 You are new to the care unit. You have to administer a new and experimental drug, but you don t know its side effects. You wonder whether you can administer it. Situation What would you do? Would you administer the drug or not? What section(s) of Division III of the Code of Ethics can guide you in your decision? Given your ethical duties and obligations, if this situation occurred in your practice, would you make the same decision? If not, please explain. The Code of Ethics of Nurses 17

22 A nurse working in the same hospital as you is visiting her mother in law, who is on your unit. She asks to see the woman s record so that she can better understand her condition. You wonder whether you can let her consult her mother in law s record. Situation What would you do? Would you let her consult her mother in law s record? What section(s) of Division II of the Code of Ethics can guide you in your decision? Given your ethical duties and obligations, if this situation occurred in your practice, would you make the same decision? If not, please explain. Section 1 18

23 You are a nurse specializing in foot care and would like to publish an advertisement in your neighbourhood newspaper. You are looking for diabetic clients. You wonder whether you can state in your advertisement that your services are more personalized than those of other nurses, given your experience with this clientele. Situation What would you do? Would you include this statement in your advertisement or not? What section(s) of Division VIII of the Code of Ethics can guide you in your decision? Given your ethical duties and obligations, if this situation occurred in your practice, would you make the same decision? If not, please explain. The Code of Ethics of Nurses 19

24 You are coming off the day shift, when your colleague working the night shift calls to tell you she will be about 20 minutes late. This inconveniences you, because you have to pick up your children at the daycare. The nursing assistant who is working the evening shift suggests that you leave, saying that she and the orderly will keep an eye on your section. You wonder whether you can leave, given the circumstances. Situation What would you do? Would you leave or not? What section(s) of Division III of the Code of Ethics can guide you in your decision? Given your ethical duties and obligations, if this situation occurred in your practice, would you make the same decision? If not, please explain. Section 1 20

25 You are scheduled to work the night shift. Although you had a few glasses of wine this evening, you feel in relatively good shape. You hesitate to report for work, but you can t really afford the loss of pay if you don t. Situation What would you do? Would you report for work or not? What section(s) of Division I of the Code of Ethics can guide you in your decision? Given your ethical duties and obligations, if this situation occurred in your practice, would you make the same decision? If not, please explain. The Code of Ethics of Nurses 21

26 You are a nurse in private practice. A client you care for in his home would like you to sell him dressings, because he cannot get out to buy them himself. You wonder whether you are allowed to do so. Situation What would you do? Would you sell him the dressings or not? What section(s) of Division IX of the Code of Ethics can guide you in your decision? Given your ethical duties and obligations, if this situation occurred in your practice, would you make the same decision? If not, please explain. Section 1 22

27 You are looking for a way to improve your chances of getting a position you have applied for in the mother-child unit. You have 10 months experience in this field. When filling out the application, you hesitate between checking off less than one year s experience or 1 to 3 years experience. Situation What would you do? Would you check off less than one year s experience or 1 to 3 years experience? What section(s) of Divisions I and IV of the Code of Ethics can guide you in your decision? Given your ethical duties and obligations, if this situation occurred in your practice, would you make the same decision? If not, please explain. The Code of Ethics of Nurses 23

28 answer guide Decision: Attend the training. ExErCisE 1.1 Situation Section: 18. A nurse shall keep her or his professional knowledge and skills up to date in order to provide care and treatment in accordance with generally accepted standards of practice. Explanation: Professional competence means the knowledge, skills, attitudes and judgment a nurse needs to practise her profession, and the ability to apply them in a given clinical situation. Section 18 deals with the ethical obligation to keep her professional knowledge and skills up to date throughout her career, so that she can provide care and treatment in accordance with generally accepted standards of practice. In fact, maintaining professional competence is an ongoing process and each nurse s individual responsibility. To meet this obligation, she may read relevant articles, consult databanks of evidence, attend conferences and conventions or take training offered by an institution, particularly when it is introducing new technology. Additional reading: Ethics Update If the training offered by an employer is necessary for a nurse to be able to perform her professional duties, she is required to attend so as to acquire the knowledge and skills she needs to act competently. Professional competence, an ethical obligation, The Journal, Vol. 2, No. 4, March/April Decision: Do not take the client s Ativan. Situation Sections: 13. A nurse shall not appropriate medications or other substances, including drugs, narcotic or anesthetic preparations or any other property belonging to a person with whom she or he interacts in the practice of the profession. Section 1 24

29 14. A nurse shall not, in respect of a client s record or any report, file, research record or document related to the profession: [ ] (3) enter therein any false information; [ ] Explanation: Taking the client s Ativan would be the same as appropriating, i.e. stealing, medications belonging to her employer. Additional reading: Ethics Update In addition, entering false information in the client s record indicating that he received a dose of Ativan could interfere with the continuity of care. If the client needed Ativan, another nurse could refuse to give it to him, thinking that he had already received the prescribed dose. Falsifying, fabricating... and the Code of Ethics, The Journal, Vol. 1, No. 3, January/February Nurses and substance abuse problems: ethical responsibilities, The Journal, Vol. 4, No. 1, September/October Decision: Ask your colleague to intervene. Situation Section: 29. A nurse shall act respectfully toward the client and the client s spouse, family and significant others. Explanation: It is a nurse s responsibility to establish and maintain a professional relationship based on trust and respect for the client and his family. When a nurse feels that she is about to lose patience, for any reason, she should ask a colleague for help. If she snaps at a client or shows signs of impatience, she could jeopardize her professional relationship with the person or have her professional conduct criticized if the client later files a complaint. A nurse should withdraw or ask for help if she feels she is about to react in a way she will later regret. The Code of Ethics of Nurses 25

30 Additional reading: Ethics Update Obstacles in therapeutic relationships, The Journal, Vol. 8, No. 4, March/April Remain calm in the midst of turmoil, The Journal, Vol. 8, No. 5, May/June Situation Decision: Do not administer the medication before obtaining the necessary information, in particular its side effects. Section: 45. A nurse shall not be negligent when administering medication. In particular, when administering medication, a nurse shall have sufficient knowledge of the medication and abide by the principles and methods applicable to its administration. Explanation: A lack of knowledge regarding the new experimental drug could lead to inappropriate monitoring of the patient. To safely administer a drug, a nurse must know its class, its mechanism of action, the main therapeutic reactions and side effects, administration conditions, normal doses, contra indications and interactions with other medications. Additional reading: Ethics Update A nurse who administers medication without sufficient knowledge cannot claim to be acting prudently. She must never act without thinking, and must take all necessary precautions. Negligence can have serious consequences for the client, and even lead to death. Administering medication: reminder of ethical obligations, The Journal, Vol. 2, No. 2, November/December Section 1 26

31 Situation Decision: Do not allow the nurse to consult her mother-in-law s record. Section: 31. A nurse shall abide by the rules set forth in the Professional Code in regard to the obligation to preserve the secrecy of confidential information that becomes known to her or him in the practice of her or his profession and the cases where she or he may be released from the obligation of secrecy. Explanation: The obligation to respect the confidentiality of information is fundamental to the very principle of respect for a person s right to privacy and independence. It reinforces the concept of respect for others, who are entitled to have and keep secrets regarding information concerning themselves and to share them with whomever they wish. Additional reading: Ethics Update The information in the client s record is confidential, and the client has not waived her right to the secrecy of confidential information. Her nurse is obliged to take the steps necessary to preserve the confidential nature of information on her client. The fact that a nurse works in a hospital does not give her the right to consult all clients records. She may consult only the records of clients under her care. To consult her mother-in-law s record, the other nurse would first have to obtain the client s consent. Disclosure of confidential information. Amendments to the Code of Ethics of Nurses, The Journal, Vol. 3, No. 1, September/October Decision: Do not include this statement. Situation Section: 71. In her or his advertising, a nurse may not compare the quality of her or his services with the quality of the services provided or that may be provided by other nurses, and may not discredit or denigrate such services. The Code of Ethics of Nurses 27

32 Explanation: Nurses in private practice may use advertising to promote their services. They may mention their expertise, but they may not compare their services with those offered by other nurses, or discredit or denigrate other nurses services. Additional reading: Ethics Update Looking for clients? How to juggle employment and private practice while keeping your professional distance, The Journal, Vol. 6, No. 5, May/June Situation Decision: Do not leave without ensuring that the clinical monitoring required by clients condition will be provided. Sections: 43. A nurse who is providing care and treatment to a client may not abandon him or her without a serious reason. 44. A nurse shall not be negligent in the care and treatment provided to the client or to the research subject. In particular, a nurse shall: [ ] (3) take reasonable measures to ensure continuity of care and treatment. Explanation: A nurse is responsible for providing safe, quality care for the clients assigned to her. Before finishing her shift, she must be sure that the care required by her clients state of health will continue to be provided. Relying on the nursing assistant and orderly as a temporary solution to her problem is not an acceptable way to ensure clients safety. They do not have the competence required to maintain the continuity of care in the absence of the nurse. The solution would be to have another nurse take over. Remember that a nurse may not abandon her clients without a serious reason. Section 1 28

33 Additional reading: Ethics Update Making enlightened decisions about overtime, The Journal, Vol. 2, No. 1, September/October Decision: Do not report for work. Situation Section: 16. In addition to the circumstances contemplated by section 54 of the Professional Code (R.S.Q., c. C-26), a nurse shall refrain from practising her or his profession when she or he is in a state that is liable to impair the quality of care and services. In particular, a nurse is in a state that is liable to impair the quality of care and services if she or he is under the influence of alcoholic beverages, drugs, hallucinogens, narcotic or anesthetic preparations or any other substance which may cause intoxication, a diminution or disruption of the faculties or unconsciousness. Explanation: Nurses must refrain from practising when they are in a state liable to impair the quality of care and services. The Disciplinary Council considers practising the profession with faculties impaired by drugs, alcohol or any other substance one of the most serious offences from a professional point of view, given the high risk of harm to clients. The complexity of care, the nature of decisions to be made and the often high-risk actions nurses are called on to take require constant vigilance, and also that a nurse must be in complete possession of her faculties and be able to exercise proper judgment at all times. Clients are entitled to receive safe care and to expect the nurse caring for them to be in a fit condition to practise her profession. Additional reading: Ethics Update Nurses and substance abuse problems: ethical responsibilities, The Journal, Vol. 4, No. 1, September/October The Code of Ethics of Nurses 29

34 Situation Decision: Sell him the dressings and tell him what profit you are making, if any. Section: 78. A nurse may not sell, engage or participate for profit in any distribution of medications, equipment or products related to her or his professional activities, except in the following cases: (1) where a sale of products or equipment is made in response to an immediate need of the client and is required for the care and treatment to be provided. In such case, the client shall be notified of any profit realized by the nurse upon the sale; [ ] Explanation: When a client is unable to obtain a product, a nurse may sell it to him to simplify his life. If the nurse makes a profit on the sale, she must tell the client so that he can make an informed decision. Additional reading: Ethics Update Think before making the sale!, The Journal, Vol. 7, No. 3, January/ February Decision: Check off less than one year s experience. Situation Sections: 10. A nurse shall fulfill her or his professional duties with integrity. 14. A nurse shall not, in respect of a client s record or any report, file, research record or document related to the profession: [ ] (3) enter therein any false information; [ ] 47. A nurse shall not intentionally mislead, betray the good faith of or engage in unfair practices toward a person with whom she or he interacts in the practice of the profession. Section 1 30

35 Explanation: Integrity is a professional value that not only must be reflected in professional relations with clients, but must also be at the basis of the nurse s relations with the people with whom she interacts in her practice. Integrity, after all, is considered by lawmakers to be the very foundation of ethical duty. Additional reading: Ethics Update In addition, checking off 1 to 3 years experience would be considered entering false information in a document related to the profession. Lastly, lying about one s experience in order to obtain a position is an unfair practice and is forbidden as it could jeopardize clients safety or mislead them. Falsifying, fabricating... and the Code of Ethics, The Journal, Vol. 1, No. 3, January/February Honesty and fairness in nurses relations with others in the practice of the profession, The Journal, Vol. 4, No. 3, January/February The Code of Ethics of Nurses 31

36 EXERCISE 1.2 Determining the appropriate professional conduct in situations involving issues related to the Code of Ethics This is a problem-solving exercise. The three situations described below require you to think about the appropriate professional conduct in situations affecting the quality of care and services. To complete the exercise, we suggest that you: 1. read the description of the situation carefully; 2. do the suggested readings, so that you can determine the best approach; 3. examine the problem using the Code of Ethics worksheet. Use the Code of Ethics worksheet presented below to document your problemsolving approach and break it down into three steps. This will let you identify the ethical issue and consult the Code of Ethics of Nurses to determine the appropriate professional conduct. Once you have decided a strategy, you can check your answer by referring to the annotated worksheets in the answer guide on page 40. Section 1 32

37 Code of Ethics worksheet Identify the problem Determine the significant clues in the situation and identify the nature of the problem. 1 Significant clues Obvious or probable signs that there is a problem. Behaviours, reactions, context and circumstances of the situation that make it possible for a problem to arise. 2 Ethical issue The ethical problem to be avoided or resolved. Consult the Code of Ethics of Nurses Identify and apply the appropriate sections of the Code of Ethics of Nurses. Decide on a strategy Determine the actions to be taken to avoid or resolve the problem. These actions and behaviours sum up the appropriate conduct. This conduct must be consistent with the ethical duties and obligations of Quebec nurses. The Code of Ethics of Nurses 33

38 Situation Lucy is a research nurse at a university hospital centre. She is collaborating on a study of a drug treatment targeting leukemia. The protocol has been approved by the centre s research ethics committee. Her responsibilities include recruiting research subjects and obtaining their consent. She then fills out a questionnaire on their state of health, takes blood samples and gives them the relevant information on the drugs they will be taking. A few months after the study begins, she is instructed by the principal investigator to recall ten subjects for bone marrow analyses. Since these analyses were not included in the research protocol, Lucy wonders whether she needs to obtain the clients consent again. She mentions this concern to the principal investigator, who tells her that he needs this new data at this precise point in the drug therapy. The changes to the protocol have been submitted to the ethics committee, but it will be too late if they wait for the committee s approval and the data will be lost. The researcher asks Lucy to notify the ten subjects and set up appointments for the blood samples, pending the committee s official approval. He says that in his opinion, the changes to the protocol will be accepted before the blood samples are taken. He explains that he wants to present his research findings at a conference to be held shortly. Lucy checks the consent form signed by the subjects and sees that only blood samples are mentioned. What would be the appropriate professional conduct for Lucy in this situation? Use the worksheet on the next page to work out your answer. Ethics Update Additional reading Nurses ethical obligations and patients consent to care, The Journal, Vol. 2, No. 3, January/February Section 1 34

39 Code of Ethics worksheet 1 Significant clues Identify the problem Situation Consult the Code of Ethics of Nurses 2 Ethical issue Decide on a strategy The Code of Ethics of Nurses 35

40 Situation Chantal is a nurse in the emergency ward. It has been very busy this evening and the staff members are overwhelmed. She is starting to feel tired and finding it increasingly difficult to concentrate. One of her clients, a 72-year-old woman, is under observation for abdominal pain. Mrs. Dorismon is very anxious, gesticulating wildly and walking up and down the corridor, although she has been instructed to stay in her bed. Her family asks the nurse to immediately administer medication to ease her discomfort. Chantal sees that her client has a prescription for Dilaudid, and gives her some. Five hours later, Mrs. Dorismon is again in pain. As she is preparing the analgesic, Chantal realizes that she gave her client a double dose the first time. Could she have been distracted? Since the double dose had no consequences for her client, Chantal wonders whether she should consider this a medication error. The client is doing well. Does the attending physician have to be told? What would be the appropriate professional conduct for Chantal in this situation? Use the worksheet on the next page to work out your answer. Additional reading Ordre des infirmières et infirmiers du Québec ( 2009). Surveillance clinique des clients qui reçoivent des médicaments ayant un effet dépressif sur le système nerveux central - Avis, 2 e éd., Montreal, OIIQ. Ethics Update Incidents and accidents now reported, The Journal, Vol. 1, No. 1, September/October Administering medication: Reminder of ethical obligations, The Journal, Vol. 2, No. 2, November/December Section 1 36

41 Code of Ethics worksheet 1 Significant clues Identify the problem Situation Consult the Code of Ethics of Nurses 2 Ethical issue Decide on a strategy The Code of Ethics of Nurses 37

42 Situation Annie is a nurse at a CLSC. She has been providing home care for the past six years, and is coming back from a one-year maternity leave. She receives a call from Mrs. Lajoie, who is taking care of her husband at home. For two weeks now, he has been receiving care from the CLSC for wounds on his right foot. She explains to Annie that her husband is finding it difficult to adapt to the intermittent mode of the drainage device, particularly at night. She also tells her that the exudate has been pinker for two days. Mrs. Lajoie tells Annie that her colleague had suggested that she set the device to continuous mode if her husband became uncomfortable. She asks Annie whether she should make this adjustment, or stop the treatment during the night. Annie consults the current treatment plan and notes that the portable wound drainage device (VAC ) is supposed to be in intermittent mode. She has read an article on this subject, but never had any training on the use of the device. She knows that it is a negative-pressure device that avoids scarring in the case of complex wounds. Wound care is an activity reserved for nurses and calls for more and more specific knowledge these days; Annie is not familiar with this new technology. What would be the appropriate professional conduct for Annie in this situation? Use the worksheet on the next page to work out your answer. Ethics Update Additional reading Professional competence, an ethical obligation, The Journal, Vol. 2, No. 4, March/April Section 1 38

43 Code of Ethics worksheet 1 Significant clues Identify the problem Situation Consult the Code of Ethics of Nurses 2 Ethical issue Decide on a strategy The Code of Ethics of Nurses 39

44 answer guide Annotated worksheet Identify the problem 1 Significant clues The nurse is collaborating on a research project approved by the research ethics committee. Taking bone marrow samples is not included in the protocol. The amendments to the protocol requested by the principal investigator for these samples have not yet been approved by the research ethics committee. 2 Ethical issue Can the nurse now call the research subjects to come in and give bone marrow samples? EXERCISE 1.2 Situation Consult the Code of Ethics of Nurses Relevant section: 41.1 (2) According to section 41.1 (2) of the Code, free and informed consent must be obtained when there is any significant change in the research protocol. Decide on a strategy The nurse must wait until the amended research protocol has been approved by the research ethics committee and obtain new consent from subjects before calling them in to take bone marrow samples. Section 1 40

45 Annotated worksheet Identify the problem 1 Significant clues Chantal realizes that she has administered a double dose of Dilaudid. The administration of this double dose had no consequences for the client. 2 Ethical issue Must Chantal report this medication error, even though there were no consequences? Situation Consult the Code of Ethics of Nurses Relevant section: 12 According to section 12 of the Code, a nurse must report any incident or accident that results from her intervention or omission. This means that she must report it officially, for example by informing the head nurse or the physician, by entering a note in the client s records or by completing an incident-accident report. The section also states that the nurse must not try to cover up the incident or accident and must immediately take steps to correct the situation or to limit or remedy its consequences. Public protection demands that the error be reported immediately. To err is human, but covering up is deliberate and it could deprive the client of the care required to deal with the resulting consequences. Decide on a strategy Chantal must report the accident, by informing the physician and completing a hospital incidentaccident report. The Code of Ethics of Nurses 41

46 Annotated worksheet Identify the problem 1 Significant clues Annie is not very familiar with this new technology. She has read an article on the subject, but has never had any training on using the device. 2 Ethical issue Can Annie change the treatment plan for Mr. Lajoie s wound? Situation Consult the Code of Ethics of Nurses Relevant sections: 17 and 18 According to section 17 of the Code, a nurse must act competently. In particular, she must take into consideration the limits of her knowledge and skills. This means that a nurse must refuse to do an activity if she lacks the required competence or if she recognizes her limits in a given situation. As stated in section 18 of the Code, professional competence means the knowledge, skills, attitudes and judgment a nurse needs to practise her profession, and the ability to apply them in a given clinical situation. Maintaining professional competence is an ongoing process and each nurse s individual responsibility. Decide on a strategy Annie cannot change the treatment plan for Mr. Lajoie s wound, given her current knowledge. She must consult a colleague or a wound care nurse. Afterwards, she could ask her employer to give her training on the VAC device. Section 1 42

47 the professional relationship The second part of our examination of the Code of Ethics of Nurses deals with the professional relationship between a nurse and her client. Fundamentals To be able to respect the ethical duties and obligations inherent in the nurse/ client relationship, you must understand the nature of the professional relationship and its underlying principles and recognize its boundaries. Nature of the professional relationship Several sections of the Code of Ethics of Nurses deal with the relationship between nurses and their clients, in particular the relationship of trust to be established, the steps to be taken to preserve the secrecy of confidential information and prohibited professional behaviour. There are three basic elements underlying the professional relationship between a nurse and her client: Trust: When a person consults a nurse for a health problem, he has no control over what happens to him. He is often insecure, and this makes him feel somewhat vulnerable. He is automatically drawn to place his trust in the nurse and expects that she will not abuse it. He relies on a health professional with special knowledge and skills that he lacks and that he needs to solve his health problem. an imbalance of power between the two. A nurse has access to privileged information on her client. She is the one with the expertise, and this situation gives her authority and influence. Intimacy: The very nature of nursing creates physical, emotional and psycho- logical intimacy. However, the relationship between a nurse and her client is unequal, because he must agree to answer personal questions and agree to have her touch him, sometimes in private places. In her practice, a nurse must show excellent communication skills and great compassion. The Code of Ethics of Nurses Power: Although the nurse is certainly on the client s side, there is always _Sec1_ALDO-EN_2851_F.indd 43 1/12/10 10:51:03 AM

48 A professional relationship differs from a social relationship in various ways (see the table on the following page). Aside from the elements already mentioned, it is also distinguished by the structured framework in which it occurs, by the fact that it is limited to the care setting and lastly, by the fact that a nurse is paid to provide care for the client. A professional relationship encompasses the therapeutic relationship, which is limited to the period of care ending when the client is discharged whereas a professional relationship can extend beyond the time of discharge. All these elements give a nurse power that she must not abuse. The relationship with the client must instead be established with a view to creating a partnership between the two, characterized by mutual respect and the achievement of a common goal. It is up to the nurse to establish the boundaries of this relationship. Boundaries of the professional relationship Recognizing the boundaries of this relationship calls for great professional judgment on a nurse s part, for there are grey areas where things are not always clear. A nurse must remain vigilant, so as not to step outside the bounds of her professional relationship. If she cares for clients at home or over a long period, she is particularly exposed to the risk of becoming involved in the private lives of the client and those around him. A nurse must not share confidences with her client, unless it meets a therapeutic need. For instance, a nurse could talk about her personal experience as the mother of a Down syndrome child to a client in the same situation, to help her overcome her troubles. This type of intervention, common in the therapeutic relationship, must always be for the purpose of the client s well-being and not the nurse s personal interest. It must be remembered that the therapeutic relationship ends when the client is discharged. The professional relationship, however, may extend over a longer period. It is not possible to set a precise deadline, for a nurse deals with many clients in different situations. She must be able to examine all aspects of the situation and be cautious when making a professional judgment concerning the length of the relationship. Section 1 44

49 Characteristics Purpose of the relationship Professional relationship (nurse-client) To provide the client with care. The relationship is structured. Characteristics of the professional relationship and the social relationship Social relationship (i.e. friendship, romance) To satisfy a need for affection or show interest in someone. The relationship is spontaneous, not structured. Location of the relationship Balance of authority Responsibility for the relationship Requirements of the relationship Remuneration Time devoted to the relationship The location is defined and limited to the nursing care setting. The relationship is unevenly balanced, since the nurse exercises power owing to her expertise, knowledge, influence and access to privileged information on the client. The nurse, and not the client, is responsible for establishing and maintaining a professional relationship. The professional relationship requires special knowledge, skills and aptitudes. The nurse is remunerated for the care provided to the client. The time devoted to the relationship depends on the employment setting and organization of care. The location is often undefined and no restrictions apply. The relationship is relatively balanced. Both parties share responsibility for establishing and maintaining the relationship. No specific requirements. No remuneration. Personal decision. Length of the relationship The professional relationship encompasses the therapeutic relationship, which ends when the client is discharged. The professional relationship may extend beyond this period, depending on the client s vulnerability, health problems, length of the period of care and the likelihood of having to care for the client again. The relationship may last a lifetime. Source: Professional Boundaries for Registered Nurses: Guidelines for the Nurse-Client Relationship, Alberta Association of Registered Nurses, 1998 (adaptation, OIIQ) The Code of Ethics of Nurses 45

50 Section 38 of the Code of Ethics describes the main criteria to be taken into account when establishing the length of the professional relationship: [ ] For the purpose of determining the duration of the professional relationship, the nurse shall take into consideration, in particular, the client s vulnerability, the nature of the client s health problem, the duration of the course of treatment and the likelihood of the nurse having to provide care to the client again. The client s vulnerability may stem from a variety of factors, including his personal situation (divorce, recent bereavement, support network); worries about his health problem. The health problem may be physical or mental, acute or chronic. The duration of the course of treatment may vary from a few hours to a few weeks, months or years. The nurse may have to provide care to the client again because of frequent hospitalizations or follow-up as an outpatient or in the home. The nurse is responsible for setting the boundaries of the professional relationship. She must first assess the situation as objectively as possible, including her own behaviour toward the client. It is recommended that she speak to a colleague or her immediate superior, for instance, as soon as she has any doubts. After assessing the situation, the nurse may realize that she is in danger of crossing the boundaries of the professional relationship. She must then decide on the best way of avoiding this, while focusing on the client s well-being and safety. If she has to end the therapeutic relationship, she must tell the client and ensure that she is replaced by a competent person. The transition must be carried out with respect for the client. Section 1 46

51 Reading This is a good time to read the articles on the professional relationship published in the Ethics Update column of the OIIQ Journal, to prepare for the next two exercises. Knowing the basic principles of a professional relationship - Part 1, The Journal, Vol. 7, No. 4, March/April The professional relationship, a special balance Part 2, The Journal, Vol. 7, No. 5, May/June Respecting the boundaries of a professional relationship Part 3, The Journal, Vol. 8, No. 1, September/October Reacting in time to safeguard the boundaries of a professional relationship Fourth and final part, The Journal, Vol. 8, No. 2, November/ December The professional relationship: How long does it last?, The Journal, Vol. 1, No. 4, March/April The Code of Ethics of Nurses 47

52 EXERCISE 1.3 Determining the nature and boundaries of the professional relationship In this exercise you are asked to determine the nature and boundaries of the professional relationship in three real-life situations. To check your answers, consult the answer guide on page 51. Sophie is a nurse in a rehabilitation centre, where she is caring for a young man who has become quadriplegic as a result of a skiing accident. Charles is very nice and reminds her of one of her sons who is also a competitive skier. Charles has been hospitalized for four months. Sophie notices that she often asks her colleagues to switch assignments with her so that she can take care of Charles. She feels that her care is more personalized. The young man has also told her that his days go by faster when she is at his bedside, which makes her feel very good. She often dreams of giving him a surprise by inviting him out to the ski hill at Christmas and taking him down the hill in a sled adapted for disabled users. Situation May Sophie take Charles out skiing? Explain. Section 1 48

53 Pierre, a nurse in the hemodialysis unit, cared for Martine, a young client with chronic renal impairment, for two years. He very much enjoyed looking after her when she came to the hospital every week. Now she is receiving home dialysis services under the supervision of a nurse clinician. Martine invites Pierre to visit her at home on his days off. Situation May Pierre accept Martine s invitation? Explain. Josée is a nurse in the orthopedic unit. She is caring for Mr. Wilson, who had an operation to repair a fractured femur. She notices that he asks her several questions about her private life. She gives him evasive answers, but senses that he is interested in her. He leaves the hospital after three days. Mr. Wilson lives in Josée s neighbourhood, and the two of them meet by chance at a street party two months later. He says he would like to see her again to get to know her better and perhaps to establish an intimate relationship. Situation May Josée accept his invitation? Explain. The Code of Ethics of Nurses 49

54 Section 1 50

55 answer guide Decision: Sophie may not take Charles skiing. EXERCISE 1.3 Situation Explanation: The nurse in this situation has struck up a friendship with Charles and perhaps even sees him as a sort of son. This relationship exceeds the boundaries of simply providing care, and satisfies the nurse s own needs. She would like to make him happy by organizing a special ski outing, but this initiative is not part of her duties and is not part of the care she is responsible for giving him. Since the therapeutic relationship for rehabilitation lasts a long time, respecting boundaries is especially difficult. Given the clues showing Sophie that she is in danger of stepping outside these boundaries, she should discuss the situation with the head nurse or a colleague, to ensure that she maintains her professional relationship with the client. Decision: Pierre may not accept Martine s invitation. Situation Explanation: Although the therapeutic relationship is over, their professional relationship is not. For one thing, Pierre took care of Martine for two years. Secondly, she still requires follow-up now provided by the nurse clinician, but Pierre might be required to care for her again. Consequently, if Pierre visited her at home, it would be to provide social support and friendship and to show his interest in the client, and these are not part of the clinical follow-up. Decision: Josée may accept Mr. Wilson s invitation. Situation Explanation: Since the period of care was short and the acute physical health problem required no follow-up by the nurse, Josée may consider that enough time has gone by for the professional relationship to be over. The Code of Ethics of Nurses 51

56 Determining the appropriate professional conduct in situations relating to the professional relationship EXERCISE 1.4 This is a problem-solving exercise. The two situations described below require you to think about the appropriate professional conduct so as to maintain the nurse/client relationship. To complete the exercise, we suggest that you: 1. read the description of the situation carefully; 2. do the suggested readings, so that you can determine the best approach; 3. examine the problem using the professional ethics worksheet. Use the professional ethics worksheet presented below to document your problem-solving approach and break it down into three steps. This will let you identify the professional ethics issue and consult the Code of Ethics of Nurses to determine the appropriate professional conduct. Once you have decided on a strategy, you can check your answer by referring to the annotated worksheets in the answer guide on page 58. Section 1 52

57 Code of Ethics worksheet Identify the problem Determine the significant clues in the situation and identify the nature of the problem. 1 Significant clues Obvious or probable signs that there is a problem. Behaviours, reactions, context and circumstances of the situation that make it possible for a problem to arise. 2 Ethical issue The professional ethics problem to be avoided or resolved. Consult the Code of Ethics of Nurses Identify and apply the appropriate sections of the Code of Ethics of Nurses. Decide on a strategy Determine the actions to be taken to avoid or resolve the problem. These actions and behaviours sum up the appropriate conduct. This conduct must be consistent with the ethical duties and obligations of Quebec nurses. The Code of Ethics of Nurses 53

58 Situation Beatrice has been a psychiatric nurse for 15 years. She has taken various training courses to keep her knowledge of psychiatric care up to date. In team meetings, her colleagues appreciate her competence. She has been caring for Frederick, a 36-year-old man, for a month now. He was admitted for severe depression and a suicide attempt, his first, after a bitter divorce. Frederick is to be discharged at the end of the week. As Beatrice is planning his discharge with him, he takes the opportunity to tell her that she has been an important part of his therapy, and how much he has appreciated her competence and empathy. He says he would like to see her again, on a personal basis. Beatrice had already sensed on a number of occasions that Frederick was attracted to her. She had enjoyed talking about his divorce with him, since she was also going through a separation, and had shared her personal experiences with him as a way of helping him. She knows that other colleagues will be dealing with Frederick s case on an outpatient basis over the coming year. The therapeutic nurse/client relationship had developed to her satisfaction. Now that their professional relationship has suddenly taken this delicate turn, Beatrice wonders how to give him an answer that will not hurt him. She knows that Frederick is very sensitive to rejection they have worked with him at length on this topic during his stay. What would be the appropriate professional conduct for Beatrice in this situation? Ethics Update Additional reading Section 1 54 Knowing the basic principles of a professional relationship - Part 1, The Journal, Vol. 7, No. 4, March/April The professional relationship, a special balance Part 2, The Journal, Vol. 7, No. 5, May/June Respecting the boundaries of a professional relationship Part 3, The Journal, Vol. 8, No. 1, September/October Reacting in time to safeguard the boundaries of a professional relationship Fourth and final part, The Journal, Vol. 8, No. 2, November/ December The professional relationship: How long does it last?, The Journal, Vol. 1, No. 4, March/April 2004.

59 Code of Ethics worksheet 1 Significant clues Identify the problem Situation Consult the Code of Ethics of Nurses 2 Ethical issue Decide on a strategy The Code of Ethics of Nurses 55

60 Situation Isabella, a 38-year-old woman, is hospitalized in the gynecology unit for surgery. She has two boys, 8 and 10 years old, from her first marriage. After looking into her case, the attending physician tells her that it would be best for her to have a hysterectomy. Isabella remarried two years ago. Her husband, Gregorio, has stayed close to her during her hospitalization and is asking many questions about his wife s condition. The nursing staff has noticed that he seems quite anxious. When she is about to sign the consent form for the operation, Isabella asks to speak privately with Julie, her nurse. She is crying and tells the nurse that her husband is determined to have children. She is worried about his reaction to the hysterectomy, and has decided not to tell him right away what surgery she is scheduled for on the next day. She asks Julie not to say anything to him about her hysterectomy for the moment. On the day of the operation, Gregorio comes to the nursing station and asks to speak to Julie. He is worried at seeing Isabella so pale, and wants to know about the surgery. The nurse tells him that his wife returned from the operating room only one hour ago, and that her post-operatory condition is normal. He asks, in an anxious tone, what kind of operation she had, and says he has the right to know. The nurse tells him that Isabella will explain what type of surgery she had, when she is able. Gregorio insists. What would be the appropriate professional conduct for Julie in this situation? Ethics Update Additional reading Remain calm in the midst of turmoil, The Journal, Vol. 8, No. 5, May/June Respect in the relationship between nurses and clients, The Journal, Vol. 2, No. 5, May/June Disclosure of confidential information. Amendments to the Code of Ethics of Nurses, The Journal, Vol. 3, No. 1, September/October Section 1 56

61 Code of Ethics worksheet 1 Significant clues Identify the problem Situation Consult the Code of Ethics of Nurses 2 Ethical issue Decide on a strategy The Code of Ethics of Nurses 57

62 answer guide Annotated worksheet Identify the problem 1 Significant clues The nurse has been caring for a client admitted for a severe depression and suicide attempt, for the past month. He says he would like to see her again, on a personal basis. She knows that the client will be receiving follow-up treatment as an outpatient. She has enjoyed talking with him about his divorce, since she is in the same situation. She shared her personal experiences with her client to help him cope. 2 Ethical issue How can the nurse maintain their professional relationship? EXERCISE 1.4 Situation Consult the Code of Ethics of Nurses Relevant section: 38 According to section 38 of the Code, a nurse may not establish a personal friendship or an intimate, amorous or sexual relationship with a client for the duration of the professional relationship. She must be attentive to the dynamic developing in her relations with clients. A nurse must be able to recognize signs that she is at risk of exceeding the boundaries of the professional relationship. She is the one who must establish these boundaries. Decide on a strategy In this situation, Beatrice must tell Frederick that, as a nurse, she cannot enter into any other kind of relationship with him. She must remember that the professional relationship may continue long after the therapeutic relationship, given the client s health problems and risks of recurrence. If she had any doubts about the risks of exceeding the boundaries of the professional relationship, her strategy would then be to discuss the matter with her colleagues, a superior or a person able to advise her on professional ethics issues. Section 1 58

63 Annotated worksheet Identify the problem 1 Significant clues Isabella confides to the nurse that she is worried about her husband s reaction and has decided not to tell him right away that she is going to have a hysterectomy. On the day of the operation, her husband insists on knowing what operation Isabella has had. Situation Consult the Code of Ethics of Nurses Relevant section: 31 According to section 31 of the Code, a nurse must abide by the rules concerning the obligation to preserve the secrecy of confidential information that becomes known to her in the practice of the profession, unless the client has authorized her to disclose this information. 2 Ethical issue Is the nurse allowed to disclose to Gregorio the type of surgery his wife has had? Decide on a strategy To preserve the secrecy of the confidential information, Julie may not tell Gregorio what type of surgery his wife had. She may offer to help Isabella discuss the surgery with Gregorio, if Isabella wishes. The Code of Ethics of Nurses 59

64 Section 1 60

65 professional independence and conflicts of interest The third part of our examination of the Code of Ethics of Nurses deals with the nurse s professional independence and conflicts of interest. Fundamentals Professional independence A nurse must show professional independence in the course of her professional activities, i.e. practise her profession with objectivity and disregard any intervention by a third party that could affect the performance of her professional duties to the detriment of the client. The Code of Ethics of Nurses The following exercise will help you determine whether you have properly understood the concept of professional independence _Sec1_ALDO-EN_2851_F.indd 61 1/12/10 10:52:32 AM

66 Recognizing the elements of professional independence ExErCisE 1.5 In this exercise you are asked to recognize and note the elements of professional independence in each of the two situations described below. Then you can check your answer by referring to the annotated worksheets in the answer guide on page 64. A foot-care nurse is asked to provide foot care twice a week for diabetic clients. While she is at the private medical clinic, she notices advertisements on the walls for different firms. She tells the owner that she does not promote the products of any specific company, but that she advises clients, if applicable, on the type of products required in their situation, and that they can buy them wherever they choose. She asks the owner of the clinic to note in her contract that she is free to use those products that she deems necessary for her clients. Situation What has the nurse done to safeguard her professional independence? Section 1 62

67 A nurse has to assess the pain of a client who is beginning a new analgesic therapy. The client is known in the healthcare community and, the last time she was hospitalized, she filed a complaint about certain nurses, including the nurse who is to conduct this assessment. Situation How could this situation compromise the nurse s professional independence? The Code of Ethics of Nurses 63

68 answer guide Answer: She is not agreeing to promote a specific product. ExErCisE 1.5 Situation She chooses the products she uses based on their effectiveness and the client s needs. She clarifies the situation in writing, to make sure that she is not influenced in her practice by any obligation toward the clinic. Situation Answer: The nurse might find it difficult to ignore the complaint filed against her. If so, that could compromise her objectivity when assessing the client s level of pain. Section 1 64

69 Fundamentals Conflict of interest All nurses may occasionally find themselves in a conflict of interest in their day-to-day practice. This situation occurs when the interests concerned are such that the nurse may be influenced to favour her own interests over those of her client or the nurse s judgment and loyalty toward her client may be unfavourably affected. Such interests may be of a personal or other nature. The conflict may be real, apparent or potential. A real conflict is a situation in which a conflict has occurred or is occurring. For instance, a nurse who is responsible for assessing supplies in a hospital agrees to promote a specific company s product in return for a paid vacation trip. An apparent conflict is a situation that could reasonably be interpreted as a real conflict. An apparent conflict may exist whether or not there is a real conflict. For instance, a nurse who is an expert in caring for wounds always uses a given company s products and encourages others to do likewise. A potential conflict is a situation in which there are interests involved that could come into conflict, although they have not as yet. For example, a nurse who is a member of a research ethics committee and has a stake in a given company that might at some point submit a research protocol for consideration. Conflicts of interest observed in the nursing context most often involve money, information or influence. Conflicts involving money can occur both in the nurse/client relationship and in relations between nurses and the industry. They originate with anything that has monetary value and that compromises or appears to compromise the nurse s professional decisions. The Code of Ethics of Nurses 65

70 A nurse places herself in a conflict of interest when she receives, in addition to the remuneration to which she is entitled, any rebate, commission or benefit related to her professional activities. A rebate or commission is a refund, a price reduction or a share in the profits. The term benefit refers to a profit, good, advantage, interest, gain or privilege. The expression pecuniary benefit refers to a gain, remuneration or reward. A material benefit is a tangible benefit or property. It may take various forms, ranging from a gift to a tip or bonus. A gift is something offered to someone to please her, such as a donation or a present. Conflicts involving information occur when a nurse uses privileged information obtained in the performance of her duties or confidential information contained in a client s record, for example. A nurse is in a conflict of interest, for instance, if she takes advantage of her work at a healthcare establishment to appropriate a pregnant woman s contact information so as to offer her a prenatal course as a self-employed worker. Nurses are required by law (see section 2, on legal considerations) and the Code of Ethics of Nurses to safeguard the confidentiality of all information on their clients that they obtain in the performance of their duties. Conflicts involving influence occur when a nurse uses her influence to obtain a personal benefit or to benefit a third party, for instance a colleague in private practice or a member of her family. Nurses have some influence in the practice of their profession, in view of their competence and their expertise, as well as the information they possess. This means that they can influence a decision by a client or a third party, such as a business, with a view to obtaining direct or indirect benefits for themselves or another party. There is also a conflict of interest when a secondary benefit, such as financial gain, information and influence or personal prestige, can unduly influence a nurse s judgment. In the performance of her professional duties, a nurse must display professional independence and avoid any conflict of interest. Section 1 66

71 Reading At this point we suggest that you prepare for the following exercise by reading pages 1 to 11 of the Order s publication, Pour des relations professionnelles intègres, Orientations à l intention des infirmières concernant l indépendance professionnelle et les conflits d intérêts. Recognizing a conflict of interest Exercise 1.6 To efficiently deal with conflicts of interest, you must first realize that they exist, and then evaluate their repercussions and the interests involved. The key part of this approach is to determine whether the situation actually or apparently interferes with the independence required for the nurse s professional judgment. We suggest that you use the acronym I-N-T-E-G-R-I-T-Y to help you recognize conflicts of interest. Remember that this moral value is viewed as the cornerstone of ethical duties. The meaning of this acronym and an example of its application in a clinical situation are presented below. The Code of Ethics of Nurses 67

72 i Indication: n Nature: t Type: e Explanation: g Gain: r Repercussions: How to recognize a conflict of interest What elements can indicate that you are in a conflict of interest? What is the nature of the conflict of interest? What type of conflict of interest is this? What exactly is the conflict of interest in this situation? What is the gain or benefit involved in the situation? What are the possible repercussions on your objectivity? Could this benefit influence your current or future decisions relating to the client or project? Would you feel obliged to someone now or in the future, in return for this benefit? i t Transparency: y You Interference: avoid the conflict: Do these repercussions compromise or apparently compromise the independence necessary for your professional judgment? Can these repercussions compromise your relationship of trust with your clients? Would you be uncomfortable if your colleagues, employer or clients learned of your behaviour in this situation? What preventive steps can you take, as spelled out in the Code of Ethics of Nurses, to avoid the conflict? Section 1 68

73 Read the following example, and then study the situations described in the following pages, using the I- N-T-E-G-R-I-T-Y acronym. Check your answers by referring to the answer guide on page 74. Exemple You are a home care nurse. To thank you for your services, one of your clients regularly gives you prepared dishes that his wife sells in her business. i Indication: n Nature: t Type: e Explanation: g Gain: r Repercussions: Interference: i t Transparency: y You avoid the conflict: You accept dishes as thanks for your services. This is a conflict of interest involving money. It is a real conflict of interest. Accepting a material benefit on top of your remuneration places you in a real conflict of interest involving money. You receive a benefit in the form of prepared dishes, representing a gift with monetary value. Accepting a gift from your client may make you feel obliged toward him. Feeling obliged toward your client could interfere with your objectivity, and affect your professional judgment. The situation could create expectations for the client, who might expect privileged attention. You would feel uncomfortable if other clients learned of your behaviour, since you would worry that they would also feel obliged to give you gifts. Prevent the conflict of interest by telling your clients that you cannot accept gifts. The Code of Ethics of Nurses 69

74 You are a long-term care nurse. You talk about your financial situation with a client who was an accountant before contracting multiple sclerosis. He offers to look over your budget for free. i Indication: n Nature: t Type: e Explanation: g Gain: r Repercussions: i Interference: t Transparency: Situation Section 1 70 y You avoid the conflict:

75 You are a wound-care nurse. You always use products from the same company, because you are happy with them. Consequently, you recommend them to your clients when they come to the outpatient clinic. i Indication: n Nature: t Type: e Explanation: g Gain: r Repercussions: Situation i Interference: t Transparency: y You avoid the conflict: The Code of Ethics of Nurses 71

76 You are a home-care nurse and you make postpartum visits. You give the names of new teenage mothers to a colleague who is recruiting subjects for nursing research. i Indication: n Nature: t Type: e Explanation: g Gain: r Repercussions: i Interference: t Transparency: Situation Section 1 72 y You avoid the conflict:

77 You are a nurse in a diabetes clinic. You hand out blood glucose meters from various companies, free of charge, when you meet new diabetic clients. One of the companies gives you a bonus of $20 whenever you give one of its blood glucose meters to a new client. i Indication: n Nature: t Type: e Explanation: g Gain: r Repercussions: Situation i Interference: t Transparency: y You avoid the conflict: The Code of Ethics of Nurses 73

78 answer guide i Indication: n Nature: t Type: e Explanation: g Gain: r Repercussions: i Interference: Your client offers to look over your budget for free. This is a conflict of interest involving money. This is a potential conflict of interest. ExErCisE 1.6 Situation Accepting a material benefit on top of your remuneration would place you in a real conflict of interest involving money. You would receive a benefit in the form of accounting services, representing a gift of monetary value. Accepting this service from your client could make you feel obliged toward him. Feeling obliged toward your client could interfere with your objectivity, and affect your professional judgment. The situation could create expectations for the client, who might expect privileged attention. t Transparency: You would feel uncomfortable if other clients learned of your behaviour, since some of them might worry that they would not receive such good care because they had not given you some token of their appreciation. y You avoid the conflict: Refuse his offer and avoid indirectly soliciting favours from clients. Section 1 74

79 i Indication: n Nature: t Type: e Explanation: g Gain: r Repercussions: i Interference: t Transparency: y You avoid the conflict: You always use products from the same company and recommend them to your clients. This is a conflict of interest involving influence. This is an apparent conflict of interest, since always recommending products from the same company could be interpreted as a potential source of a conflict of interest. Recommending products from the same company all the time puts you in an apparent conflict of interest involving influence. No gain. Clients might think that your objectivity is affected. Situation There is no interference, since there is no real or potential conflict. You would feel uncomfortable if your clients thought you were obliging them to use products only from the company in question. Objectively inform clients of all products they need given their state of health, without promoting any particular product, and allow them to make informed decisions. The Code of Ethics of Nurses 75

80 i Indication: n Nature: t Type: e Explanation: g Gain: r Repercussions: i Interference: t Transparency: y You avoid the conflict: You give the names of new teenage mothers to a colleague who is recruiting research subjects. This is a conflict of interest involving information. This is a real conflict of interest. Using privileged information obtained in the performance of your duties places you in a real conflict of interest involving information. You help a colleague recruit research subjects. Situation By helping a colleague recruit research subjects, you are disclosing confidential information without the consent of these new mothers. Using confidential information without first obtaining clients consent interferes with the relationship of trust. You would be uncomfortable if your clients learned that you had put your colleague s personal interests ahead of theirs. Do not use confidential information to obtain any direct or indirect benefits. Section 1 76

81 i Indication: n Nature: t Type: e Explanation: g Gain: r Repercussions: i Interference: t Transparency: y You avoid the conflict: You receive a bonus whenever you give new clients a blood glucose meter from a certain company. This is a conflict of interest involving money. This is a real conflict of interest. Accepting a bonus places you in a real conflict of interest involving money. You receive a benefit in the form of a bonus. Situation Accepting a bonus from the blood glucose meter company would make you feel obliged toward it. Feeling obliged toward the company could interfere with your objectivity in choosing blood glucose meters to hand out to new clients, and prevent you from telling them about the other meters available. You would feel uncomfortable if your clients learned that you are receiving a bonus. Do not accept bonuses from companies and always act in your clients best interests when you recommend materials they need, given their state of health. The Code of Ethics of Nurses 77

82 Determining the appropriate professional conduct in situations where there is a risk of a conflict of interest ExErCisE 1.7 This is a problem-solving exercise. The situations described below require you to think about the appropriate professional conduct so as to ensure your professional independence as a nurse and avoid any conflict of interest. To complete the exercise, we suggest that you: 1. read the description of the situation carefully; 2. do the suggested readings, so that you can determine the best approach; 3. examine the problem using the Code of Ethics worksheet. Use the Code of Ethics worksheet presented below to document your problemsolving approach and break it down into three steps. This will let you identify the ethical issue and consult the Code of Ethics of Nurses to determine the appropriate professional conduct. Once you have decided on a strategy, you can check your answer by referring to the annotated worksheets in the answer guide on page 86. Section 1 78

83 Code of Ethics worksheet Identify the problem Determine the significant clues in the situation and identify the nature of the problem. 1 Significant clues Obvious or probable signs that there is a problem. Behaviours, reactions, context and circumstances of the situation that make it possible for a problem to arise. 2 Ethical issue The ethical problem to be avoided or resolved. Consult the Code of Ethics of Nurses Identify and apply the appropriate sections of the Code of Ethics of Nurses. Decide on a strategy Determine the actions to be taken to avoid or resolve the problem. These actions and behaviours sum up the appropriate conduct. This conduct must be consistent with the ethical duties and obligations of Quebec nurses. The Code of Ethics of Nurses 79

84 Situation Mary has been working as a nurse in an inner-city neighbourhood youth clinic for seven years. The clinic offers complete medical and psycho-social services for young people under age 18. It provides services adapted to their needs, including contraception, pregnancy and sexually transmitted diseases. Mary works as part of a multidisciplinary team. The nurses on the team are assigned in turn to clinical services, where they deal with young visitors to the clinic or answer questions over the telephone. Mary is on duty today. The young people who turn to the drop-in clinic come with urgent problems, and are often in crisis. Annie, a 16-year-old girl, comes to the clinic for a pregnancy test. The receptionist gives her a questionnaire to be filled out before she meets the nurse. When Annie hands in the questionnaire, she asks the receptionist whether the clinic offers abortion services. She is visibly upset, and has no one with her. The receptionist tells her that Mary, the nurse on duty, is waiting in her office for the assessment interview and will be happy to answer all Annie s questions. Mary is surprised to see that her client is her son s new girlfriend. Annie is also surprised, and becomes even more anxious. She starts to cry and says she needs help, because she is pregnant. She came to the youth clinic because one of her girlfriends at school had been to the clinic before and told her they could help. Mary listens as the young girl pours her heart out. What would be the appropriate professional conduct in this situation? Section 1 80

85 Code of Ethics worksheet 1 Significant clues Identify the problem Situation Consult the Code of Ethics of Nurses 2 Ethical issue Decide on a strategy The Code of Ethics of Nurses 81

86 Situation Francine is a wound-care nurse at a university hospital centre. As a stomatherapist she is up to date on the latest findings in the field of wound care. She also works on developing treatment plans for certain types of wounds in her work setting. Different products from various companies are used in wound care. Sales repre sentatives often meet with specialists to promote their products and learn about new needs. This collaboration sometimes makes Francine uncomfortable, although it is necessary for clients well-being and an accepted part of pharmaceutical sales. The sales representative from the ZY Company would like to promote a new product, and asks Francine to give a sample of a barrier ointment to all new wound clients she treats. At the same time he gives her a pass to a symposium to be held the following summer, at which a number of subjects of interest to Francine will be discussed. What would be the appropriate professional conduct in this situation? Section 1 82

87 Code of Ethics worksheet 1 Significant clues Identify the problem Situation Consult the Code of Ethics of Nurses 2 Ethical issue Decide on a strategy The Code of Ethics of Nurses 83

88 Situation Denise is a long-term care nurse. She has been working at a residential centre for two years. Mrs. Marcado, a 70-year-old resident, was admitted to Denise s unit after a severe stroke. She is hemiplegic on her right side and is aphasic. Despite spending time at a rehabilitation centre, she has not recovered enough autonomy to be able to return home. Denise has been caring for Mrs. Marcado for six months. Her husband comes every day, from 1 to 8 p.m., and is very much involved in caring for his wife. Denise has come to know the couple well and sometimes drops in during her afternoon break to discuss Mrs. Marcado s case with her husband. He has several times invited her to have a coffee with them. During one of these conversations, Denise mentions that her young daughter is a real snowboarding enthusiast, but that Denise cannot afford to share this pastime with her. Mr. Marcado often tells Denise that he is very happy with the care his wife is receiving. He says, with a tear in his eye, that the centre feels like his second home. A few days before Denise leaves on vacation, he discreetly hands her an envelope with a gift certificate for a ski centre in the Laurentians. He says it is a small token of thanks for the good care she has given his wife. Denise is confused, and very touched at his thoughtfulness. What would be the appropriate professional conduct in this situation? Ethics Update Additional reading Yes or no to gifts? Establishing limits in a professional relationship can save you some worries, The Journal, Vol. 7, No. 2, November/December Section 1 84

89 Code of Ethics worksheet 1 Significant clues Identify the problem Situation Consult the Code of Ethics of Nurses 2 Ethical issue Decide on a strategy The Code of Ethics of Nurses 85

90 answer guide Annotated worksheet Identify the problem 1 Significant clues Her son s girlfriend comes to the drop-in clinic for a consultation regarding an unplanned pregnancy. 2 Ethical issue May the nurse deal with Annie? ExErCisE 1.7 Situation Consult the Code of Ethics of Nurses Relevant section: 21 According to section 21 of the Code, a nurse must safeguard her professional independence at all times. She must practise her profession with objectivity. Consequently, she must ensure that her professional judgment is not affected by family ties or friendships. Decide on a strategy Deal with the immediate crisis facing the young client, within the constraints of a professional relationship. Ask a colleague to take over the assessment interview and follow up with the client. Tell the client that her confidentiality will be protected at all times. Section 1 86

91 Annotated worksheet Identify the problem 1 Significant clues The sales representative asks the nurse to give a product sample to all new clients she treats. He gives her a free pass to a symposium dealing with a number of subjects that interest the nurse. Situation Consult the Code of Ethics of Nurses Relevant sections: 21, 23 (2) and (3) The nurse may distribute the samples to clients provided that the product meets their needs. However, the nurse may not promote the product or benefit from it. 2 Ethical issue May the nurse give a product sample to new wound clients? May she accept the pass to the symposium? Decide on a strategy Francine should give a sample of the product to clients who need it, depending on her clinical assessment, but refuse the pass to the symposium. However, she could suggest to the representative that his company contribute an equivalent amount to the Council of Nurses or the Nursing Department, for instance, to support nursing training. The Code of Ethics of Nurses 87

92 Annotated worksheet Identify the problem 1 Significant clues The nurse takes breaks with the client and her husband. The nurse has confided in them about her financial situation. The client s husband gives the nurse a gift certificate to express his appreciation. 2 Ethical issue May the nurse accept the gift certificate? Situation Consult the Code of Ethics of Nurses Relevant sections: 21, 23 (2) Accepting a gift would place the nurse in a situation where she was potentially obliged to reciprocate. She could feel indebted to the client and do her a favour, which would interfere with her objectivity in deciding what care to give her. Decide on a strategy Refuse the gift, since accepting it could create expectations that could undermine the professional relationship and place the nurse in a conflict of interest. She must remain vigilant in the professional relationship, especially over the long term, in particular by not confiding in the client or her husband regarding her personal problems or financial situation. Section 1 88

93 Section 2 other legal considerations for Quebec Nurses The second section of the self-study guide deals with other legal considerations for Quebec nurses. This part looks at the legal framework governing the practice of the profession, and then the client s rights with respect to health care and the nurse s professional liability.

94 Section 2 90

95 Fundamentals Legislative framework governing nursing in Quebec Nurses in Quebec are considered professionals, meaning that they are obliged to display competence and integrity and have full ethical and civil liability. Quebec legislation imposes obligations that must guide nurses in their practice. To practice safely, nurses must know and understand their legal obligations so as to be able to exercise their judgment in such a way as to respect and protect their clients rights. This section examines the relevant provisions of certain pieces of legislation: Charter of Human Rights and Freedoms; Civil Code of Québec; Act respecting health services and social services; Act respecting the protection of persons whose mental state presents a danger to themselves or to others; Youth Protection Act; Act respecting Access to documents held by public bodies and the Protection of personal information. The Professional Code and the Nurses Act, which govern the professional system and the field of practice of nursing, respectively, will not be discussed here. clients rights with respect to health care A number of Quebec laws give clients rights that nurses must protect and respect. More specifically, these rights are laid out in the Charter of Human Rights and Freedoms, the Civil Code of Québec and the Act respecting health services and social services. It is important that nurses be familiar with the relevant provisions of these laws, so that they understand the resulting obligations. Charter of Human Rights and Freedoms Other Legal Considerations for Quebec Nurses 91

96 The Charter of Human Rights and Freedoms is the cornerstone of the legislative system in Quebec. It gives everyone the rights and freedoms they need to develop their autonomy and make informed choices in accordance with their own interests. These fundamental rights and freedoms include: the right to life, and to personal security, inviolability and freedom (s. 1); the right to assistance (s. 2); freedom of conscience, freedom of religion, freedom of opinion, freedom of expression, freedom of peaceful assembly and freedom of association (s. 3); the safeguard of their dignity, honour and reputation (s. 4); respect for their private life (s. 5); non-disclosure of confidential information (s. 9). Section 10 of the Charter guarantees all individuals the right to full and equal recognition and exercise of their human rights and freedoms, without distinction, exclusion or preference based on discrimination. The list of grounds for discrimination includes traditional ones such as ethnic origin, sex and religion, but also more contemporary grounds such as social condition, political convictions, pregnancy and sexual orientation. Discrimination is prohibited in juridical acts and in employment, housing and access to public places and services. From a legal point of view, a nurse who provides services is acting both as a health professional and a citizen. She is responsible for respecting the rights accorded her clients under the Charter. Civil Code of Québec The Civil Code of Québec contains basic provisions governing life in society, i.e. relations between persons and between persons and property. It deals with the status of individuals and their capacity, the organization of the family, contracts, civil liability and property. The Civil Code gives clients rights that nurses must respect, in particular: Section 2 92

97 the right of a person not to be made to undergo care without his free and informed consent. If the person concerned is incapable of giving or refusing his consent, the Code specifies who may act in his name; the right of a person to have access to his records and to make corrections to the information in those records. Information in a patient s record may not be disclosed by a professional without the consent of the person concerned. Act respecting health services and social services (AHSSS) In Quebec, the rights of users of health services are recognized in the Act respecting health services and social services. They include: the right to information on the existence of the health and social services and resources available in his community and of the conditions governing access to such services and resources; the right to receive, with continuity and in a personalized and safe manner, health services and social services which are scientifically, humanly and socially appropriate in view of the resources available; the right to choose a professional and an institution that will provide these services, in view of the organization of services at the institution and the availability of resources; the right to receive appropriate care in an emergency; the right to be informed of his state of health and welfare, the options available in view of this state and the risks and consequences associated with each option, before consenting to care. Users are also entitled to be informed, as promptly as possible, of any accident that occurred during the delivery of services which is likely to have or which has had a significant impact on his state of health or personal integrity; the right to consent to or refuse to undergo care; the right to participate in any decision affecting his situation; Other Legal Considerations for Quebec Nurses 93

98 the right to be accompanied or assisted by the person of his choice when seeking to obtain information on the services offered or to file a complaint; the right to services in the English language for English-speaking persons, insofar as there is an access program for these services for the region in question; the right to have his records remain confidential; the right of access to his records; the right to recourse in case of professional or other negligence. The Organization and Management of Establishments Regulation was adopted pursuant to the AHSSS. In the fifth chapter it deals with setting up and keeping records on beneficiaries in institutions, the contents of medical records, archiving records and their access and the contents of consent forms for surgery and anesthesia. Other acts contain provisions applicable to nursing in Quebec, in particular: Act respecting the protection of persons whose mental state presents a danger to themselves or to others The provisions of this act complement those of the Civil Code. It deals with provisional confinement ordered by a tribunal with a view to psychiatric assessment and provides, in emergencies, that a person may be confined against his will and without court authorization if his mental state presents a grave and immediate danger to himself or to others. The Act also imposes rules of procedure to ensure that the person concerned and his close relatives receive complete information and follow-up on the rights of and remedies available to the person under confinement. Youth Protection Act According to the Youth Protection Act, the primary responsibility for children rests with their parents. In some cases, however, the State must intervene, when the security or development of a child is in danger. In such cases, the Act Section 2 94

99 stipulates that any intervention in respect of a child and his parents must be designed to put an end to and prevent the recurrence of a situation in which the security or development of the child is in danger. This act applies to young people under age 18. Act respecting Access to documents held by public bodies and the Protection of personal information This act has two main objectives: it guarantees access to documents held by public bodies and confirms the principle of the confidentiality of personal information files held by public bodies. The provisions relating to nurses obligations fall mainly under this second aspect of the Act. Nurses must be familiar with the relevant sections of these acts. They are presented in Appendix II. Nurses professional liability If a nurse commits a breach in delivering nursing care that results in harm, she incurs not only professional but also civil liability. To determine whether her behaviour was negligent in terms of civil law, the tribunal considering a suit for damages must establish, in light of all the rules governing the profession, what another reasonably prudent, diligent and competent nurse would have done under the same circumstances. To conclude in favour of the plaintiff, the tribunal must also decide that the plaintiff actually suffered damages that were the result of the nurse s acts or omissions. Ignorance of the law or of standards relating to the delivery of nursing care is not a valid defence. Thus it is imperative that all nurses be familiar with the acts, regulations and standards of practice that they must respect on a daily basis in their practice. In case of doubt regarding her knowledge or skills, a nurse is obliged to obtain the assistance, support, supervision or training she needs. Other Legal Considerations for Quebec Nurses 95

100 Reading To help you understand the provisions of legislation relating to the practice of nursing, take the time to read the excerpts from the acts and regulations in Appendix II. You will also have to refer to them for the following exercises. Identifying and applying acts and regulations ExErcisE 2.1 The rights conferred on clients by Quebec legislation impose obligations on nurses that they must respect in their daily practice. The situations below will help you understand nurses legal obligations relating to client rights, in particular: the right to personal integrity; the right not to be made to undergo care without free and informed consent; the right to respect of confidentiality; the right to receive care in an emergency; the right to be informed of any accident or incident that could have consequences for their health; the right to have access to their records. Once you have completed the exercise, you can check your answers by consul ting the answer guide on page 109. Section 2 96

101 Mrs. Moreau, 74 years old, lives in a residential centre for people with decreased levels of autonomy. Every year, the centre holds a flu vaccination clinic, as recommended in the Quebec Immunization Protocol. The nurse in charge of vaccinations checks with her client whether she wishes to be vaccinated. Situation What would be the appropriate professional conduct in this situation? Explain your answer, referring to the provisions concerning free and informed consent in the Civil Code of Québec and the Code of Ethics of Nurses. Other Legal Considerations for Quebec Nurses 97

102 Veronica is a night nurse on the emergency ward in a hospital. She sees Stella, a 15-year-old, who is accompanied by a girlfriend. Stella is pale and has been experiencing severe abdominal pains since having an abortion in a clinic the day before. Based on the results of the ultrasound, the doctor wants to conduct a laparoscopy. Stella asks the nurse not to tell her parents about her situation. Situation a What would be the appropriate professional conduct in this situation? Explain your answer, referring to the provisions concerning free and informed consent in the Civil Code of Québec. Section 2 98

103 Stella has a uterine perforation, which requires a blood transfusion. She has been under observation at the hospital for 14 hours, and the doctor wants to keep her 24 hours longer. He tells her parents, who are surprised that they were not informed of their daughter s hospitalization and treatments. Situation b a) Explain why the doctor informed Stella s parents at this point, referring to the provisions concerning consent required for the hospitalization of a minor in the Civil Code of Québec. b) What would have happened if Stella s condition had required emergency surgery? Explain your answer, referring to the provisions of the Civil Code of Québec and the Charter of Human Rights and Freedoms. Other Legal Considerations for Quebec Nurses 99

104 Irene, a 34-year-old homeless drug addict, is admitted to the psychiatric ward. She is agitated and confused. She is hurting herself and acting aggressively toward other clients. Situation What provisions of the Act respecting health services and social services can the nurse use in deciding on the appropriate means of control to protect the client? Section 2 100

105 Mr. Janvier, 76 years old, is a new resident at the long-term care facility. His heart condition is worsening, and he must be transferred to the hospital, 40 minutes away. The nurse at the residential centre decides, without a medical prescription, to install an intravenous catheter and an IV drip to keep his veins from collapsing. Situation Is the nurse allowed to make this decision? Explain your answer, referring to the provisions of the Civil Code of Québec and the Charter of Human Rights and Freedoms. Other Legal Considerations for Quebec Nurses 101

106 Sonia, a 16 year old who is using injectable drugs, is brought to the hospital by the police. She has had an overdose and is in need of emergency care. Her parents ask the nurse to let them see their daughter s record. Situation What should the nurse do in this situation? Explain your answer, referring to the provisions of the Charter of Human Rights and Freedoms, the Act respecting health services and social services, and the Act respecting Access to documents held by public bodies and the Protection of personal information concerning the confidentiality of patient records. Section 2 102

107 Carl is hospitalized for multiple fractures sustained in a suicide attempt. His record indicates that he has had many stays in detoxification centres and has also had run-ins with the police for selling drugs. The orderly, who is providing the basic care, asks the nurse about Carl s background. Situation What is the nurse allowed to tell the orderly? Explain your answer, referring to the provisions of the Charter of Human Rights and Freedoms, the Act respecting health services and social services, and the Act respecting Access to documents held by public bodies and the Protection of personal information concerning the confidentiality of patient records. Other Legal Considerations for Quebec Nurses 103

108 Mr. Lee lives in a long-term care facility, where he was admitted because of a reduction in his level of autonomy. His health situation has been stable for several weeks. Situation In this situation, what are the nurse s obligations with respect to documenting his care? Explain your answer, referring to the provisions concerning the documentation of care in the Organization and Management of Establishments Regulation under the Act Respecting Health Services and Social Services. Section 2 104

109 For the second time this month, a woman shows up at the hospital emergency clinic with her 10-month-old baby, saying he fell out of bed. The nurse notes that the mother is very talkative, her pupils are dilated and she has numerous needle marks in her forearm. When the nurse asks her about her condition, she says she lives alone with her child because the father is working abroad. The child is pale and thin and has numerous bruises. The client s record notes suspicious marks on the child in the past. Situation What would be the appropriate professional conduct in this situation? Explain your answer, referring to the Youth Protection Act. Other Legal Considerations for Quebec Nurses 105

110 Following an episode of post-operative bradypnea, Chantal, the nurse, discovered a dosage error in the intravenous administration of morphine by the nurse previously caring for the client. Situation a) Once all the steps have been taken to ensure the client s safety, including notifying the physician, is Chantal obliged to report this accident? Explain your answer, referring to the Act respecting health services and social services. b) Must the client be informed of this accident? Explain your answer, referring to the Act respecting health services and social services. Section 2 106

111 Mr. Ambrose was brought to the emergency clinic following a violent street fight. He is admitted to the psychiatric ward. He has had bipolar disorder for many years now, and is currently in the manic phase. The nurse notes that he is extremely excited and unable to concentrate. He skips from one idea to the next and his mood shifts from euphoria to aggression. He says he has to settle things with the people who beat him up and wants to sign a refusal of treatment and leave the hospital immediately. Since the psychiatrist s assessment shows that there is a risk to the client s safety, a request that he be confined to the institution is made. Mr. Ambrose is angry and says he is being hospitalized against his will, and that his independence is not being respected. He asks the nurse to help him. Situation a) What provisions of the Act respecting the protection of persons whose mental state presents a danger to themselves or to others is the doctor using when he requests that Mr. Ambrose be confined to the institution? Other Legal Considerations for Quebec Nurses 107

112 b) Referring to the Act respecting the protection of persons whose mental state presents a danger to themselves or to others and the Civil Code of Québec, what information can the nurse give Mr. Ambrose about his rights in this situation? Section 2 108

113 answer guide Exercise 2.1 Situation Answer: Mrs. Moreau is an autonomous person who is capable of making her own decisions. Clients have the right to expect truthfulness, personal respect and recognition of their decision-making power, so the nurse is required to obtain her free and informed consent before vaccinating her. Article 11 of the Civil Code of Québec (C.c.Q.) clearly states the obligation to obtain this consent from clients before providing care. A person cannot be subjected to care, be it an examination or treatment, giving samples or any other intervention, without his consent. Health professionals are not authorized to make decisions about treatment in their clients stead, except in emergencies. The nurse also has ethical obligations concerning consent. According to section 41 of the Code of Ethics, when a nurse is responsible for obtaining free and informed consent, she must provide the client with all the information required for that purpose. Consent is the manifestation of express or tacit willingness by which an individual approves an act to be performed by another person. The client s consent may be implicit or explicit and may be expressed either in writing or orally. Consent is explicit when it is clear and specific. Consent is implicit when it is not expressed formally, but the context makes it possible to assume that the person consents. It is considered to be understood. A nurse who is offering care to her client is responsible for assessing the client s ability to make a decision concerning the care. Remember that the obligation to obtain consent is an ongoing process; clients may withdraw their consent at any time and are entitled to refuse treatment. Even if the nurse has obtained the client s explicit consent, she must always explain the intervention she is carrying out. Other Legal Considerations for Quebec Nurses 109

114 Answer: (Situation 2.1.1, cont d) To be valid, this consent to care must meet two requirements: it must be given freely and it must be informed. Consent is free when it is given readily with no constraint. It is not free if the decision is the result of pressure applied by another person in the form of a moral or physical constraint. Consent is informed when it is given on the basis of proper information. This requirement means that nurses have a duty to inform clients and the Code of Ethics stipulates that to do so they must provide clients with all the information required for that purpose. In theory, this duty to inform applies to what clients need to know to make an informed decision. This does not mean that nurses have to tell them absolutely everything, but enough so that clients understand what is at stake for them, in a language they understand. They must provide information on six points: the proposed care, other possible solutions, expected benefits, risks and side effects, and consequences if the client refuses. In this case, the nurse must answer the client s questions about the vaccination. It is advisable to keep notes in the file on the information provided and the client s decision, including when she refuses the care offered. In providing information about the vaccination, the nurse must refer to the Quebec Immunization Protocol, the tool for carrying out all aspects of the provincial public health program concerning immunization. It is available on the Website of the Department of Health and Social Services (MSSS) at in the Santé publique section. Click on the Vaccination tab and then on Professionnels santé. This rule of free and informed consent applies to all clients. Obviously, a person who is able to give consent will do so himself. However, if a person is incapable of giving his consent because of his age or inability to express his wishes or understand the consequences of his actions, another person must do so in his stead (e.g. tutor, public curator, spouse). This is known as substitute consent (C.c.Q., art.11). Section 2 110

115 Situation a Answer: The client has to undergo a laparoscopy, which requires consent before the operation. Minors ages 14 and over may consent alone to care required by their state of health (C.c.Q., art.14). Consequently, the nurse must not inform Stella s parents. Situation b a) Answer: The Civil Code provides that if a minor 14 years or over remains in the hospital for longer than 12 hours, his parents must be informed. Stella s doctor notified her parents of her hospitalization because she has been in the emergency ward for 14 hours. The reason for her hospitalization remains confidential, however. The law gives minors 14 years and over the right to consent alone to care required by their state of health (C.c.Q., art.14). b) Answer: If emergency surgery had been required, article 13 of the Civil Code would have applied: Consent to medical care is not required in case of emergency if the life of the person is in danger or his integrity is threatened and his consent cannot be obtained in due time. In addition, section 2 of the Charter provides that every person must come to the aid of anyone whose life is in peril. Other Legal Considerations for Quebec Nurses 111

116 Situation Answer: Section of the Act respecting health services and social services (AHSSS) stipulates that restraint or isolation are to be used as a last resort and only to prevent a person from inflicting harm upon himself or others. A nurse may decide to use restraint without a medical prescription, if the establishment has a policy to that effect. The nurse responsible for caring for Irene will have to indicate in the therapeutic nursing plan what measures are to be taken to protect the client and other clients in the care unit and how they are to be applied. This reserved activity is part of a systematic approach aimed at reducing the use of restraint by first applying effective and efficient replacement options that are respectful of the individual and his autonomy, environment and friends and family. Recourse to restraint calls for a thorough assessment of the person s health situation and the prior use of other measures, close supervision and constant re-assessment of its relevance, according to the procedure for the application of control measures adopted by the hospital. The nurse may consult the Ministerial guidelines on exceptional use of restraint, isolation and medication (Orientations ministérielles relatives à l utilisation exceptionnelle des mesures de contrôle: Contention, isolement et substances chimiques) and the associated action plan. These documents are available on the MSSS Website at under Documentation, Publications. The MSSS has also developed a course entitled Vers un changement de pratique afin de réduire le recours à la contention et à l isolement ( Toward changing practices to reduce the use of restraint and isolation measures ). The Act also states that no person may be made to undergo care except with his consent (AHSSS, s. 9). This provision is in line with the principles of inviolability of the person and the right to integrity in the Civil Code (C.c.Q., art. 10, 11). In Irene s situation, the nurse will have to obtain her consent, if she is able to give it, or else substitute consent. Section 2 112

117 Situation Answer: Given section 2 of the Charter of Human Rights and Freedoms and the first paragraph of article 13 of the Civil Code, which provide that protecting someone s life and physical integrity requires that assistance be given and the required care provided when his life is in danger, the nurse must rapidly install an IV catheter. In view of Mr. Janvier s worsening heart condition and the 40-minute trip to the hospital, his veins could collapse and compromise the care required when he arrives at the hospital, threatening his life and physical integrity. Situation Answer: Although Sonia is a minor (under 18), she is entitled to keep information concerning her confidential and divulge or share it with whomever she wishes. The information in a client s record is confidential, and the client has not waived her right to secrecy of confidential information. Her nurse is obliged to take the necessary steps to maintain the confidentiality of information concerning her client, and so must refuse to allow her parents access to their daughter s record. The record of a user is confidential and no person may have access to it except with the consent of the user [ ] (AHSSS, s. 19). Moreover, section 59 of the Act respecting Access to documents held by public bodies and the Protection of personal information confirms the right to confidentiality, as do sections 5 and 9 of the Charter, which state that every person has a right to respect for his private life and to non-disclosure of confidential information. Other Legal Considerations for Quebec Nurses 113

118 Situation Answer: The right to respect for one s private life and to non-disclosure of confidential information are stipulated in sections 5 and 9 of the Charter. In addition, the Act respecting health services and social services and the Act respecting Access to documents held by public bodies and the Protection of personal information state that information in a user s record is confidential. Consequently, the orderly, who is not part of the clinical staff, is not entitled to information in Carl s record. In accordance with section 62 of the Act respecting Access to documents, the nurse may not provide the orderly with any information other than that necessary to provide the care required by the user s health. Carl has spent time in detoxification centres and had run-ins with the police. Since this information is not necessary to provide basic care, the nurse must not disclose these details to the orderly. However, if the nurse noted a risk of suicide and instructed the orderly to help provide the necessary supervision, she could then give him the information necessary for this purpose. She would then discuss the behaviours to watch for in Carl. The Act provides that information in a client s record may be communicated, in order to prevent an act of violence, including a suicide, without the client s consent (AHSSS, s. 19.1). Section 2 114

119 Situation Answer: Documentation refers to all the information relating to nursing care placed in the client s record and the action of recording this information. The nurse caring for Mr. Lee at the centre must keep progress notes, including the therapeutic nursing plan (TNP), by providing enough information to ensure continuity of care for the client. The documentation must include information making it possible to follow the evolution of Mr. Lee s health situation, note any changes and measure the effectiveness of any interventions. Section 55 of the Organization and Management of Institutions Regulation states that records kept by a long-term care facility must include progress notes by physicians, dentists, pharmacists and members of the clinical staff, including nurses. Healthcare institutions have rules concerning documentation methods and tools and even the minimum frequency in certain cases, such as long-term care. Whatever the procedure established for documenting nursing care is, it must contribute to the continuity of care and make it easy to assess the quality of nursing care, with the goal of continuously improving the service provided for clients. For further details, nurses may consult the following OIIQ publi cations: Énoncé de principes sur la documentation des soins infirmiers. A guide to the various daily activities involved in documenting nursing care. L intégration du plan thérapeutique infirmier à la pratique clinique. Guide on the documentation standard regarding the therapeutic nursing plan and its application. From a legal point of view, the information placed in the client s record could be important evidence in a dispute. If a record is lost or incomplete, the court may conclude that the care not recorded was not given, and that the nurse was negligent. Other Legal Considerations for Quebec Nurses 115

120 Situation Answer: The nurse has reasonable grounds to believe that the 10-month-old baby has been neglected or abused. She is required to report this situation to the Director of Youth Protection, in accordance with section 39 of the Youth Protection Act. The Act prescribes the obligation to report to the Director of Youth Protection any situation in which the security or development of a child is or may be considered to be in danger. It expressly provides that under such circumstances secrecy of confidential information is not an obstacle to fulfilling this obligation and that anyone who makes such a report in good faith cannot be prosecuted. This is one of the two exceptions provided in section 9 of the Charter of Human Rights and Freedoms. This section provides that a professional bound to secrecy of confidential information may disclose confidential information only when authorized to do so by the person who confided such information to him or by an express legal provision. As specified in the Charter and the Professional Code, there are only two situations in which nurses may disclose information protected by professional secrecy: 1. With the client s authorization The secrecy of confidential information belongs to the client who gives the information. He is the one who holds this right to confidentiality. In the situation described, the mother did not talk to the nurse about any behaviour that could threaten her child s safety. Clients may waive, in whole or in part, their right to secrecy of confidential information. This renunciation may be explicit or implicit. It is explicit when it explicitly or formally authorizes the professional to divulge to a third party all or some of the information. The professional must comply with this requirement, in accordance with the conditions set by the client. Clients may also implicitly waive this right. For instance, if a person consulting a nurse is accompanied by a family member, he implicitly waives his right to confidentiality as it pertains to the family member, but only as concerns the information communicated in the presence of the family member. Section 2 116

121 Answer: (Situation cont d) 2. Where bound by law There are a number of legal provisions that authorize or require a professional to disclose information to third parties without the client s authorization. This situation of the mother who has brought her 10-month-old baby to the hospital meets the exceptional conditions allowing disclosure as set out in section 39 of the Youth Protection Act. The emergency nurse who saw the baby and noted that his security could be in danger is justified in immediately reporting this situation to the Director of Youth Protection. Situation a) Answer: The nurse must, as soon as possible after becoming aware of any incident or accident, report it to the executive director of the institution or to a person designated by the executive director (AHSSS, s ). This report is intended to prevent avoidable medical accidents, and must be made using the form provided for such purposes and placed in the client s record. b) Answer: Since the medication error had consequences on the client s respiratory state, he is entitled to be informed of the accident. The Act states that the client has the right to be informed of any accident that has actual or potential consequences for his health or welfare (AHSSS, s. 8). The purpose of these legal provisions is to enable the Quebec health network to make risk management a priority, so as to prevent avoidable accidents in the provision of health care. Other Legal Considerations for Quebec Nurses 117

122 Situation a) Answer: In accordance with section 7 of the Act respecting the protection of persons whose mental state presents a danger to themselves or to others, the doctor may temporarily place a person under preventive confinement without his consent and without court authorization. In Mr. Ambrose s case, the doctor considered that his mental state presented a serious and immediate danger to himself or others. For his own protection, the client is confined to the institution until the court makes a decision in his case. The doctor must immediately notify the director of professional services of the situation. b) Answer: In accordance with section 15 of the Act respecting the protection of persons whose mental state presents a danger to themselves or to others, Mr. Ambrose must be informed of the reasons for his confinement and of his right to contact his close relatives and an advocate. The nurse must inform the client of his right to receive information on his care and on his confinement in the institution and of his right to consult an advocate regarding this confinement. The Civil Code of Québec provides that consent to medical care is not required in case of emergency if the person s life is in danger (art. 13). Although Mr. Ambrose is legally able to give consent, he cannot exercise this right for the moment, given the danger he presents to himself. The nurse must explain to him that he is being confined to the institution for his safety so that the treatment necessary to better assess the care required for his well-being can be undertaken. Confining Mr. Ambrose by force constitutes interference with his personal integrity. The nurse responsible for his care must do her best to mitigate this interference, by ensuring that all his rights are respected. Section 2 118

123 Section 3 other ethical considerations for Quebec Nurses The final section of the self-study guide looks at other ethical considerations for nurses in Quebec. This part deals with nurses ethics as well as personal and professional values. It also includes exercises that call for considering the Code of Ethics of Nurses, clients rights and the legislation governing nursing practice.

124 Section 3 120

125 Fundamentals Ethics In this guide the term ethics refers to a way of thinking about values and standards concerning professional conduct. It is applied ethics, calling for dialogue and an open mind. In ethics, values reflect the importance assigned to beliefs, ideas, attitudes, customs or traditions and objects. They reflect needs, social and cultural influences and relations with other people. Generally speaking, a person s values evolve as she acquires maturity and life experience, and continue to guide her actions. This evolution often leads to changes in the priority or importance assigned to certain values, leading to changes in attitudes and behaviour. As she strives to clarify her values, she comes to better understand the choices she makes and the reasons for her actions. This exercise develops her discernment and prudence, two prerequisites for openness to others and the ability to accept diverging opinions, overcome resistance and sustain dialogue. Reflecting on her personal and professional values prepares a nurse to understand the values of clients and their families as well of those of her colleagues, and to interact appropriately in situations when values are or appear to be in conflict. Personal and professional values Personal values have an influence on the choice of a profession. It is recognized that nurses have profound respect for the individual and for life, and that they are naturally disposed to express this respect in their professional conduct. Most often a nurse s personal values are in line with professional values. Other Ethical Considerations for Quebec Nurses 121

126 The Code of Ethics of Nurses is inspired by the values essential to ethical nursing practice. In addition to respecting the unique and inviolable character of the individual, nurses show compassion and place great importance on the quality of services and care they provide. They respect others independence, private lives and quality of life. Clients well-being and safety are at the heart of nurses concerns, along with justice and equity in providing care. Nurses also recognize the importance of maintaining a relationship of trust with their clients. They strive to collaborate with other health professionals and hence value the concepts of responsibility and accountability linked to professional independence. They feel that competence and the quality of nursing care are inseparable and consequently see it as essential to keep their knowledge up to date. These professional values are reflected in the delivery of care and in relations between nurses and their clients. The following section contains a number of exercises dealing with the values that apply to nursing in Quebec. These values are defined below, so that you can refer to them while doing the exercises. Definitions of values compassion The sentiment or attitude of wishing to comfort and assist another person who is suffering in some way. competence The knowledge, skills, attitudes and judgment a nurse needs to practise her profession and her ability to apply them in practice. integrity A fundamental value considered to be the cornerstone of ethical duty, guiding a nurse s attitudes and behaviours toward her clients. This is reflected in her candour, honesty and fairness. interprofessional collaboration A situation in which various health professionals work together in the client s best therapeutic interests. Section 3 122

127 Justice and equity Moral qualities that allow a nurse to treat clients objectively, so they receive the share of health services and resources to which they are entitled, in accordance with their needs. Professional independence The ability to make the necessary professional decisions, appropriate to the situation (responsible) and to be accountable for them. Relationship of trust with clients The establishment, development and maintenance of a professional relationship of trust with clients, allowing them to confide in the nurse with complete confidence. Respect for human dignity Recognition of the unique and inviolable character of a human being, from the beginning to the end of his life. Respect for human life Recognition of the importance of protecting human life. Respect for privacy Recognition of a person s right to be spared any unwanted intrusion into his private life, so as to protect his interests and physical, psychological, spiritual and cultural integrity. Respect for quality of life Recognition of the obligation to pay particular attention to the client s health and well-being, as he sees it and expresses it according to his own standards. Safety A situation in which there is no danger or in which the person feels safe, that she has nothing to fear and can trust those around her. Self-determination A person s ability to make decisions independently concerning herself. Other Ethical Considerations for Quebec Nurses 123

128 ExERciSE 3.1 Determining values In order to recognize a conflict in values, you must first identify the values involved. Referring to the above definitions, identify the values at work in the three situations below. Once you have completed the exercise, you can check your answers by consulting the answer guide on page 129. Nadia is a 23-year-old nurse. She has just discovered that she is pregnant. She has been living with Mark for two years, and supporting him while he completes his studies in engineering. They had decided to start a family once Mark completes his degree and finds a job. This was an unplanned pregnancy. Nadia is uncomfortable. She wants the child, but Mark would rather wait until he has finished his studies. He suggests that she have an abortion and promises to be there for her. Nadia can t accept this solution. She has talked the situation over with him openly a few times. She tells him she wants to have the child and her arguments are in favour of continuing her pregnancy. She says that she finds the idea of abortion repugnant and that the life she is carrying deserves to be protected. She feels privileged to be fertile, unlike her sister, who is unable to have children despite many treatments. She feels that although this is not an ideal time to have a child, it would be selfish to sacrifice the child s life so as not to compromise the quality of their life as a couple. On the other hand, she is aware of the risk that she could lose her partner if she decides to have the child against his wishes. Nadia tells Mark that she is psychologically ready to bear the child, that she doesn t think that he is ready for this, but that she is determined to have the child. Situation Section 3 124

129 a) What value is guiding Nadia s actions in this situation? b) What value is guiding Mark s actions in this situation? Other Ethical Considerations for Quebec Nurses 125

130 During her postpartum follow-up home visits, a nurse encourages new mothers to breastfeed. One of the mothers she visits wants to stop breastfeeding her newborn. An evaluation of the situation confirms that the client has made an informed decision that meets her needs and conforms to her values. The nurse explains how to wean the baby and gives her advice to ease the transition to bottle feeding. Situation a) What values are guiding the nurse s professional conduct in this situation? b) Explain your answer. Section 3 126

131 A nurse who has worked in mental health for 10 years is transferred to the major burns unit after her position is abolished. She is aware that her new assignment calls for specialized skills if she is to provide quality care. At her meeting with the new department head, she tells him that she needs to update her knowledge and outlines the steps she has taken to find an appropriate educational setting. She tries to negotiate intensive, short-term remunerated training. The department head studies her proposal. Situation a) What values are guiding the nurse s professional conduct in this situation? b) Explain your answer. Other Ethical Considerations for Quebec Nurses 127

132 An elderly homeless man with serious psychiatric problems and hallucinations is brought to the emergency clinic by ambulance. The client presents with a very foul body odour and talks loudly and incoherently. The emergency staff knows him already, as he has been admitted several times in the past to the psychiatric ward to treat his schizophrenia. His behaviour creates a stressful atmosphere in the care unit. Situation a) What values should guide the professional conduct of the nurse assigned to the client in this situation? b) Explain your answer. Section 3 128

133 answer guide Exercise 3.1 Situation a) Value: The value guiding Nadia s actions is respect for human life. She clearly states the main value guiding her choice that is her respect for the life growing inside her. She also bases her choice on her desire to have the child and her ability to ensure the baby s security and wellbeing. She also considers her fertility a privilege. b) Value: Mark s actions are guided by the principle of quality of life. He sees his quality of life as more important and feels that it would be upset by the arrival of a baby. His priority now is to obtain his engineering degree. The quality of the couple s relationship is an indispensable element in his pursuit of his professional goals. The arrival of a baby would compromise his quality of life. Situation a) Values: The values guiding the nurse s professional conduct are competence, her relationship of trust with the client, and respect for the client s right to self-determination. b) Explanation: Although the nurse encourages breastfeeding, she respects the client s decision, after confirming that the client has made an informed decision and can take responsibility for it. She offers the client her expertise, clearly explaining how to wean the baby and switch to bottle feeding, so as to ensure the baby s health and well-being. Other Ethical Considerations for Quebec Nurses 129

134 Situation a) Values: The values guiding the nurse s professional conduct are competence and professional independence. b) Explanation: The nurse recognizes the limits of her competence in caring for major burn patients. She is also able to evaluate her training needs herself and discusses them openly with her employer. She recognizes that it is her responsibility as a professional to keep her knowledge and skills up to date so as to practise safely and competently. She acts conscientiously by suggesting solutions. Situation a) Values: The values that guide the nurse s professional conduct are respect for human dignity, justice and equity. b) Explanation: The nurse provides the client with care regardless of his social situation. She respects his needs and ensures that he receives the care required by his state of health. She respects the client s well-being, while thinking about the well-being and safety of other clients in the care unit. Section 3 130

135 Exercise 3.2 Recognizing conflicting values A conflict in values is a difference of opinion arising from opposing values, beliefs or tastes, different personality types or social norms. Nurses usually share professional values that correspond to their personal values. Sometimes these values do not match, and give rise to conflict. A conflict in values can occur within the healthcare team, when there is a difference of opinion between clients and professionals, between professionals or between clients and family members. To solve the conflict, it is important first of all to identify the opposing values. This is an essential skill that nurses must acquire and develop to solve conflicts in values that can occur in their professional practice. In the following three situations, determine the values involved and explain how they are conflicting. Once you have completed the exercise, you can check your answers by consulting the answer guide on page 138. Other Ethical Considerations for Quebec Nurses 131

136 A nurse is talking about palliative care with a man in the terminal phase of his illness. He has been a widower for three years and has four children. The nurse has been caring for him for several months and is well aware of his physical and mental suffering. He is very troubled by his approaching death, and asks the nurse to help him. He tells her that he does not want to be resuscitated. He asks her about possible options if he can no longer drink nor eat. After listening to her explanations, he says that he refuses to receive intravenous fluids, that he does not want to prolong his suffering. The nurse records his wishes in his file and recommends that he tell his children, so that they are ready for this situation. After a few weeks, the client s condition worsens. He is not eating and has great difficulty drinking. His periods of lucidity are increasingly rare. The family has trouble dealing with this situation and asks that an intravenous drip be installed, regardless of their father s wishes. They feel that intravenous hydration is a question of comfort that should be given their father in his last hours. The nurse reiterates the client s wishes concerning hydration. She knows that it is her role to have the client s wishes respected and to help his family cope with this final phase in their father s life as easily as possible. She feels uncomfortable about the situation and wonders about the conflicting values. Situation Explain the conflicting values facing her in this situation. Section 3 132

137 Other Ethical Considerations for Quebec Nurses 133

138 Tania, a young teenager, consults the CLSC nurse about an abortion. She wants to continue her college studies. Her boyfriend is also a student, and both of them live at home. Tania says she has always wanted children, but that her current social and financial situation means that she wouldn t be able to offer her child the proper quality of life. Her parents are well off and have offered to support her financially if she keeps the baby. According to their religious beliefs, they must encourage their daughter not to have an abortion. Tania does not want to submit to her family s wishes. She worries about being too dependent on her parents. Her boyfriend feels that an abortion is the right solution at this time. Tania worries about grieving over her unborn child to such an extent that it could interfere with her studies and her relationship with her boyfriend. She asks the nurse to explain what happens after an abortion. Maria, the CLSC nurse, had a similar experience with her own daughter. She had encouraged her daughter to keep her child and offered to support her. Maria feels that life is sacred and that parents have a duty to encourage their children not to have abortions. Situation a) Explain the conflicting values facing the nurse in this situation. Section 3 134

139 b) What value guided Maria s conduct with her own daughter? c) What value should guide Maria s professional conduct with Tania, the teenager who is not her daughter? d) What professional conduct should Maria adopt with the teenager who is not her daughter? Other Ethical Considerations for Quebec Nurses 135

140 During a meeting at a long-term care facility, the multidisciplinary team discusses the choice of residents to be taken on an outing to a sugar shack. Several of them have requested to go. The five-hour outing means using adapted transportation, and is very tiring for the accompanying staff. The health professional in charge of the activity says that she wants to avoid overworking the accompanying staff, so as to ensure everyone s safety. The nurse mentions the special case of one resident who recently had a stroke and has been making good progress in his bladder re-education. She thinks that refusing to take him on the outing could affect his morale. For the past month, his episodes of urinary incontinence have occurred only rarely, in the early morning. In addition, when he takes part in activities at the centre he sometimes wears adult diapers as a precaution. The resident is very keen to go on the outing, especially since it is in the village where he was born. He has gone to the sugar shack every year since he was a boy, and this trip would mean a lot to him. He thinks that he can take part without being a burden on the staff. The nurse asks the team to reconsider his request, as he will see it as encouragement for the progress he has made. The health professional hesitates to add this resident to the group. She wants to avoid overworking the staff, as this could compromise the group s safety. The nurse suggests that the resident be allowed to go, provided that he respects his urination schedule and agrees to wear an adult diaper. In the end, the resident is allowed to go along on this outing that is so important to him. Situation Explain the conflicting values facing the nurse in this situation. Section 3 136

141 Other Ethical Considerations for Quebec Nurses 137

142 answer guide ExERciSE 3.2 Situation Explanation: This is a conflict between the client s values and those of his children, between his right to self-determination and their respect for his wellbeing. The nurse wants to respect the client s last wishes, as he was capable of deciding for himself when he made them, in particular his refusal of resuscitation and IV hydration. She respects his right to self-determination: he made a free and informed choice concerning possible treatment at the end of his life. She also understands the client s children when they ask for IV hydration, even though they know it goes against their father s last wishes. They feel that it is a matter of respect for his well-being. Their father s independence is in question. The end of a person s life is difficult for all concerned. The client expressed his wishes concerning his terminal treatment. It is important that the family understand the reasoning of the person who has reached the terminal phase of his illness, so as to accompany him at this time. The nurse must advocate the client s viewpoint, since he is no longer able to make himself heard to his family. Situation a) Explanation: This is a conflict between the nurse s personal and professional values: respect for human life and the client s right to self-determination. In her personal and family life, the nurse gives priority to respect for human life. She finds herself in a clinical situation in which the teenager she has a duty to help has values different from her own. Her personal values are in conflict with her professional values that require her to respect the client s right to self-determination. Section b) Personal value: The value that guided Maria s conduct with regard to her own daughter is respect for human life.

143 c) Professional value: The value that must guide Maria s professional conduct with Tania is respect for the teenager s right to self-determination. d) Professional conduct: Maria must set aside her personal values and adapt her professional conduct to the duties and obligations spelled out in section 30 of the Code of Ethics of Nurses. She must comply with the teenager s wishes, after making sure that she has properly thought through her decision. Situation Explanation: This is a conflict between the nurse s own values and those of the health professional: respect for the resident s quality of life, and the safety of all participants. The nurse argues in favour of the resident s qualify of life, citing the progress he has made in his bladder re-education, so that he can enjoy an experience that means a lot to him. The health professional emphasizes the safety of the residents going on the outing, by excluding an incontinent resident who could overwork the accompanying staff and jeopardize the safety of the group. Thanks to interprofessional co-operation, a solution was found so that the resident could take part in the outing without jeopardizing the others safety: he must respect his urination schedule and wear an adult diaper during the outing. Regardless of whether the health professional is a physician, a physiotherapist or another professional, a conflict in values can be resolved provided that the professionals involved work together to meet the client s needs and keep his interests in mind. Other Ethical Considerations for Quebec Nurses 139

144 Determining the appropriate professional conduct in situations involving ethical issues ExERciSE 3.3 In this last part of the section dealing with ethics, you will be asked to consider both the provisions of the Code of Ethics of Nurses and the applicable legislation as you study two clinical situations in which the values of the persons concerned may conflict (health professionals, caregivers, clients and significant others). We recommend that you use the ethics worksheet to help you determine the appropriate professional conduct when there is a problem involving ethics in a clinical situation. The first step is to recognize the conflict in values, by identifying significant clues and specifying the nature of the ethical problem. To do so, read the description of the situation and identify obvious or probable signs of a conflict between personal and professional values, a conflict between the nurse s values and those of the client and his family, or a conflict between the nurse s values and those of her colleagues. Then identify the conflicting values that are creating discomfort either on the part of the client and his family or within the healthcare team. The second step is to examine the ethical problem in light of the applicable regulatory framework, i.e. the relevant provisions of the Code of Ethics of Nurses and legal conside rations, including client rights. The third step is to decide on a strategy, i.e. the actions to be taken to foster dialogue between the individuals concerned in the client s best interests. This strategy must be consistent with the applicable regulatory framework you have identified. You have two situations to examine. After reading the description of the situation, complete the ethics worksheet, following the three steps described above to determine the appropriate professional conduct in the situation. You can then compare your answers with the explanations provided in the annotated worksheet by consulting the answer guide on page 148. There are no right or wrong answers in applied ethics. You are looking for the best line of Section 3 140

145 conduct, or the least harmful one in the circumstances. This exercise is intended to encourage you to think about how to deal with a clinical situation involving an ethical problem. In complex ethical situations, nurses may consult the clinical ethics committee of the institution, which is responsible for analyzing clinical cases that raise specific ethical problems. The committee draws up guidelines reflecting the applicable legislation and ethical principles to guide the conduct and attitudes of all concerned. For issues relating to research, a research ethics committee at the institution makes sure that projects respect the dignity, well-being and rights of research subjects, and that all ethical requirements are considered. The committee also ensures that all research is carried out in accordance with the underlying ethical principles. Ethics worksheet Identify the conflicting values Determine the significant clues in the situation and identify the nature of the ethical problem. 1 Significant clues Obvious or probable signs that there is a conflict in values between: the nurse s personal and professional values the nurse s values and those of the client and his family the nurse s values and those of her colleagues Behaviours, reactions, context and circumstances of the situation that make it possible for a problem to arise. 2 Conflicting values The conflicting values that create unease either on the part of the client and his family or within the healthcare team. Examine the ethical problem in light of the applicable regulatory framework Take into account relevant professional ethics and legal considerations. Decide on a strategy Determine the actions to be taken to foster dialogue between the individuals concerned, in the client s best interests. Prioritize the values involved. Determine the actions and behaviours that sum up the appropriate conduct. This conduct must be consistent with the prioritized values and the regulatory framework applicable in the situation. Explain the strategy. Other Ethical Considerations for Quebec Nurses 141

146 Situation Norma is a nurse in the pediatric ward, and has been caring for a 10-year-old boy with acute lymphoblastic leukemia. Bruno is well known to the staff, as he has been receiving intensive chemotherapy treatments for several years. He has been fighting the disease bravely, but his situation has now been complicated by severe pneumonia, which is being treated with antibiotics. His parents are with him. They are well aware of the progress of leukemia and the complications related to treatments. Bruno is running a fever and having trouble breathing. A large mass in the mediastinum is interfering with his breathing. He has bone pain due to infiltration of the bone marrow. The least shift or pressure on a bone makes him jump, because the pain is intolerable. The physician prescribed morphine: 0.05 to 0.2 mg/kg/dose sc q 4 h or q 2-4 h i.v. and a breakthrough dose of 0.1 mg/kg/dose sc prn. Norma notes that, just like her, some of her colleagues are not administering the breakthrough doses, because of Bruno s respiratory state. They are worried the medication is exacerbating his respiratory depression. Bruno is not eating and drinks a little. He says he is exhausted, and cries because of the pain. He often says, in his parents presence, that he does not want this chemotherapy any more, as it is making him sicker. His parents talk about their worries concerning the refractory pain with Norma, and wonder about the chemotherapy treatments. They want their son s suffering to be relieved as much as possible, and that he be made comfortable, in view of how his condition is progressing. Norma has to admit to herself that the child s pain is starting to bother her as well. Section 3 142

147 Ethics worksheet Identify the conflicting values 1 Significant clues Situation Examine the ethical problem in light of the applicable regulatory framework 2 Conflicting values Other Ethical Considerations for Quebec Nurses 143

148 Decide on a strategy Section 3 144

149 Situation Aline Tremblay, age 75, is suffering from Alzheimer s dementia. The disease first appeared one year ago. She has been admitted to the geriatric ward following an abrupt deterioration in her condition. Her husband, Maurice Tremblay, who has been taking care of her at home, observed disturbing personality changes. She is manifesting unrealistic fears and often refuses to eat or take her medication. She is agitated and confused and lately has been falling at home. Mr. Tremblay tells Sylvia, the nurse, that their children feel that it would be safer to place their mother in a longterm care facility. He would prefer to obtain assistance to keep her at home. This difference of opinion is creating family tensions that are making life difficult for Mr. Tremblay and the caregivers. Mrs. Tremblay absolutely refuses to be separated from her husband; she flies into rages when he leaves at night. Sylvia attends a meeting of the multidisciplinary team to discuss the client s situation. She presents her assessment of the situation: Mrs. Tremblay is calmer when her husband is with her, and lately she has rarely refused to take her medication; she manages to eat when the staff gives her dishes one at a time and encourages her to eat; her husband participates in caring for her and is proving very helpful; he has read up on the disease, talks with groups of natural caregivers and, until now, has never called on home-care services. Sylvia feels that this support could make it easier to care for Mrs. Tremblay and improve the quality of their life together. A home-care nurse could help, if the couple agreed to this solution. The client s daughter has been delegated by her brothers and sisters to attend the meeting and explain their request that their mother be placed in a long-term care facility. She says they are concerned about their mother s safety, and that she worries about her father s health, at age 79. She explains that her brothers and sisters cannot offer more assistance to their parents, because they work and live far from the family home. Their father, she says, is not being realistic about the care required by their mother s condition. If she came back to the house it would mean more worry and the need for extra help, which would have consequences on their families quality of life. They see this solution as a burden imposed on them. Sylvia explains that the client is now being assessed to determine whether she is capable of consen ting to care. Mr. Tremblay is the mandatary designated by his wife if she is incapable. He has already told the nurse that he wants to respect his wife s wishes to return home, and he feels that her quality of life will be better if she remains in familiar surroundings. The physician confirms that Mrs. Tremblay s cognitive disorder has worsened and that an adjustment in her medication could stabilize her condition. The daughter mentions that her mother often refuses to take her medication. She believes that her mother s condition is bound to deteriorate and that her father will have to provide more and more care. She feels that it would be irresponsible on the part of the health professionals to encourage her father to keep his wife at home. Other Ethical Considerations for Quebec Nurses 145

150 Ethics worksheet Identify the conflicting values 1 Significant clues Situation Examine the ethical problem in light of the applicable regulatory framework 2 Conflicting values Section 3 146

151 Decide on a strategy Other Ethical Considerations for Quebec Nurses 147

152 answer guide Annotated worksheet Identify the conflicting values 1 Significant clues The nurses are not administering breakthrough doses of morphine, because they are worried about respiratory depression. The parents want their son s pain to be relieved as much as possible. 2 Conflicting values Conflict between the nurses values and those of the parents regarding pain relief. The parents give priority to their son s quality of life through the optimal administration of analgesics. The nurses give priority to respect for human life by not administering the breakthrough doses of analgesics, so as to avoid respiratory depression. ExERciSE 3.3 Situation Examine the ethical problem in light of the applicable regulatory framework Right to information regarding treatments Civil Code of Québec, art. 10, 11, 14; Code of Ethics of Nurses, s. 40; Act respecting health services and social services, s. 8, 9, 12 (1). The nurse s role in relation to Bruno s parents is to give them all the information they need to make an informed decision regarding his pain relief, in view of the possible side effects of morphine. Respect for the values of the client and his parents Charter of Human Rights and Freedoms, s. 1; Code of Ethics of Nurses, s. 30; Act respecting health services and social services, s. 3 (1), (2), (4). Bruno and his parents have stated what they want, in view of how his condition is progressing. Respect for their values is essential to establishing a relationship of trust. Section 3 148

153 Decide on a strategy Priority value Respect for quality of life. Appropriate actions and behaviour Optimal pain relief. Explanation Bruno and his parents want optimal pain relief and palliative care appropriate to his evolving condition. They clearly state that his quality of life depends on the effective relief of his pain. The nurse must give Bruno s parents all the necessary explanations regarding the care provided for their son, in particular the therapeutic effects of morphine and its side effects on the state of consciousness and breathing. The nurse objectively assesses the child s pain and tries to ease his pain properly, according to the medical prescription, by administering the required breakthrough doses. She talks with her colleagues and the physician about ways of providing optimal pain relief, and palliative care appropriate to the child s evolving condition. She adjusts the therapeutic nursing plan by giving instructions for optimal pain relief. Other Ethical Considerations for Quebec Nurses 149

154 Annotated worksheet Identify the conflicting values 1 Significant clues Mr. Tremblay is the mandatary designated by his wife in case of incapacity. He wants to respect her wishes by having her return home. They both feel that her quality of life will be better if she remains in familiar surroundings. The children want their mother to be placed in a long-term care facility, for her own safety and their father s health. They cannot offer additional assistance to their parents, because they work and live far from the family home. 2 Conflicting values Conflict between the parents values and those of their children, concerning the right living environment for the client. Situation Examine the ethical problem in light of the applicable regulatory framework Free and informed consent Civil Code of Québec, art. 10, 11, 15, 16; Code of Ethics of Nurses, s. 40, 41; Act respecting health services and social services, s. 8, 9, 10, 12 (2), (3). It is primarily up to Mrs. Tremblay to consent to care and to decide whether to return home. A thorough assessment will determine whether she is capable of giving her consent. If not, it is her husband who represents her. Respect for the couple s values Charter of Human Rights and Freedoms, s. 1; Code of Ethics of Nurses, s. 30, 39; Act respecting health services and social services, s. 3 (1), (2), (3). Mr. and Mrs. Tremblay have clearly expressed their wishes that they want her to return home. Respect for their values is essential to establishing a relationship of trust. The parents give priority to Mrs. Tremblay s quality of life by choosing to have her remain at home. The children give priority to her safety, by choosing to have her placed in a long-term care facility. Section 3 150

155 Decide on a strategy Priority value Respect for quality of life. Appropriate actions and behaviour Support the husband and children concerning the decision as to whether Mrs. Tremblay should return home. The nurse must inform Mrs. and Mr. Tremblay regarding her state of health, the different options concerning her return home, and the home-care services available to them. Explanation Mrs. Tremblay, or Mr. Tremblay as her mandatary if she is incapable, has the right to decide on the care required. Conflict between family members is a reality that sometimes complicates a nurse s interventions. However, Sylvia must always act in her client s best interests, by not taking a position openly in the conflict between the father and his children. The nurse must reassure the children, by explaining the home-care monitoring process and answering their questions about this new experience. She must take into account the values of the client and her husband, who have chosen home care despite their children s disagreement. She must also maintain a dialogue with the other family members, to better monitor developments in the situation and support them as necessary. The nurse must also make sure to indicate the appropriate follow-up in the therapeutic nursing plan. Other Ethical Considerations for Quebec Nurses 151

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157 appendix i code of ethics of nurses

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159 Code of ethics of nurses Because we care about Quebecers health

160 Our dream for Quebecers health is that everyone will have access to quality healthcare when they need it. Lucie Tremblay

161 Message from the President Working together to shape nursing care for tomorrow This updated version of the Code of ethics of nurses more than ever reflects the dream we all share. It is the most extensive update of the past decade. It will give Quebec nurses the means to adapt our everyday practice to Quebecers new healthcare needs, as it now covers the authorization to prescribe, psychotherapy practice, the assessment of mental disorders, and the use of assessment tools and social media. Because we believe that nurses must receive the best possible training to keep pace with rapidly evolving scientific knowledge, health technology and social needs, this Code will be accompanied by the complementary training and communications necessary to master its contents and excel in the profession. We consider our profession s admirable reputation to be of the utmost importance, and we invite you to share any questions or concerns you may have as your updated Code of ethics comes into effect. Lucie Tremblay, Nurse, MSc, AdmA, CHE President 3

162 4 Values of the nursing profession

163 The shared values of our profession are based on its history and its culture. These fundamental values reflect the principles that guide nurses actions in their practice. All nurses adhere to these values and are committed to preserving the image and credibility of the profession. Professional ethics are intended to regulate activities performed as part of one s professional practice. They are inspired by the values that motivate professional conduct and are spelled out in professional codes of ethics. These values broadly define ideal practice, and include competence, a sense of responsibility, and social commitment. The Code of ethics helps define what this ideal means in everyday practice, by stipulating the duties and obligations arising from this shared ideal. 5

164 6 The following values served as the pillars for the different divisions of the Code of ethics of nurses and helped define the resulting professional duties and obligations. The revision of the Code updates nurses professional duties and obligations, while reaffirming the values of the nursing profession.

165 Integrity Integrity refers to honesty and truthfulness. It transcends all dimensions of the practice of the profession and is the cornerstone of nurses professional ethics. Respect for the client This means both establishing and maintaining a relationship of trust, and recognizing the client s uniqueness, right to privacy and decision-making autonomy, as expressed in his or her right to make choices and to be informed. Professional autonomy This relates to nurses ability to make objective and independent decisions in the client s interest, and to be accountable and responsible for them. Professional competence Competence refers to nurses responsibility to maintain and update their knowledge and skills and to take account of evidence-based data and best practices. It also means nurses ability to recognize and respect their limits in practising the profession. Excellence in care Excellence in care is the raison d être of the nursing profession, and reflects the importance accorded to human life. It means striving to ensure the well-being and security of clients of every age, at every stage in their lives, and is the ultimate goal of the nursing profession. Professional collaboration This value reflects the importance of acting in partnership with other professionals and individuals involved, so as to ensure and optimize the quality and security of care and services for clients. Humanity Demonstrating humanity in the provision of care means, in particular, showing generosity, tolerance and solidarity in dealings with others. It lets nurses show empathy and recognize others uniqueness. These values were adopted by the OIIQ Board of Directors in December

166 8 The Code of ethics of nurses

167 The Code of ethics of nurses is a keystone of the Order s professional legislation. The 2015 edition of this regulation is the most extensive update of the past decade. It is intended to adapt the Code to the new realities facing nurses, including the authorization to prescribe, psychotherapy practice, the assessment of mental disorders, and the use of assessment tools and social media. Many sections in the Code also deal with preserving professional secrecy and avoiding conflicts of interest. The Code of ethics informs nurses of their duties and obligations toward the public, the clients and the profession. Code of ethics of nurses (chapter I-8, s. 9) Professional Code (chapter C-26, s. 87) Nurses Act (chapter I-8, s. 3) 9

168 CHAPTER I DUTIES TOWARD THE PUBLIC, CLIENTS AND THE PROFESSION 10