Week 6- Oct 20th- Class Slides.pdf

NUSC 1P12: WEEK 6 PART 1: CHAPTER 9 NURSING VALUES AND ETHICS (Potter et al., 2024) CNA Code of Ethics CNO Code of Conduct VALUES Values are strong personal beliefs about the worth (merit) of an ideal; influence behaviour; vary among people; are at the “heart of ethics” o Consider right and wrong...

NUSC 1P12: WEEK 6 PART 1: CHAPTER 9 NURSING VALUES AND ETHICS (Potter et al., 2024) CNA Code of Ethics CNO Code of Conduct VALUES Values are strong personal beliefs about the worth (merit) of an ideal; influence behaviour; vary among people; are at the “heart of ethics” o Consider right and wrong o Some are instilled in us as children o Evolve as we age o Values and beliefs are reflected in our actions, behaviours and decisions o Can be challenged (self vs. others or context) o Consider personal and professional values VALUES FORMATION o Personal values may reflect cultural, ethic, social, religious influences/ values o Family experience and relationships o Individual experiences o Values vary among people (unique, personal) o Can develop and change over time (moral development, constantly evolving) o As future nurses, internalizing the values of our profession is an important part of professional values formation o HCPs must learn to respect the many diverse values systems clients hold while attempting to realize how differences affect health and wellness, and their interactions with us (self+other+context) Think of something you value. How/why is it important to you? When did it become important to you? Who else in your life shares this value? Who doesn’t? VALUES CLARIFICATION o The process of appraising one’s values helps a person decide priorities and make decisions. o Values may change, and a person may modify attitudes and behaviour. o Values may conflict between people and between societies. o Relational communication is important for resolving conflict. PERSONAL REFLECTION o Self-awareness is required to be conscious of your own values and biases Why should we be conscious of our values and biases? o Must consider the values you hold about life, health, suffering, illness & death o May cause conflict or moral distress (feeling like we don’t agree, can’t do right, or are doing wrong) when our personal and or professional values do not coincide with those of our clients and colleagues (self+other+context) How will our (personal) values influence us as (professional) nurses? MORALS VS. ETHICS Morals (self) o Internal (personal) understanding of how we believe we ought to act; reflection of what matters most to ME o Personal opinions on right and wrong o Action-oriented o Are my personal morals congruent with my professional code of ethics? o Moral integrity o Moral autonomy Ethics (other + context) o Philosophical ideals of right and wrong (this can vary for different people, professions, and organizations); reflection of what matters most to people or professions (to others, in a situation, in general) o How we should behave (implicit and explicit values) o Nursing has principles and values that guide and govern the ethics of our professional and individual nurses CNA Code of Ethics ICN Code of Ethics CNO Code of Conduct ETHICAL THEORIES Utilitarianism (Consequentialism) Deontology ­ The concept that the value of something is determined by its usefulness ­ Greatest good for the greatest number; end justifies the means • Right or wrong is determined by the nature of the act itself (no/ less regard for the result; actions are guided by morals) Bioethics • Guided by 4 principles; actions are obligation based, outcome oriented, and based on reason ­ Respect for autonomy: self governance, informed consent; ability to make informed personal choices ­ Beneficence: to do or promote good for others ­ Non-maleficence: avoidance of harm or hurt; to “do no harm” ­ Justice: fair and equitable; distributive justice related to resource allocation EXAMPLES OF ISSUES IN BIOETHICS/NURSING Quality of life o o o o Central to discussions about futile care (care that is prolonging suffering and life and/not deemed medically necessary, is not improving health/well-being) Cancer therapy Medical Assistance in Dying (MAID) “Do not resuscitate”/advance directives Allocating scarce resources o key issue in discussions about access to care OTHER ETHICAL THEORIES Feminist Ethics o Focuses on inequalities between people o Being attentive to issues of difference, power dynamics, and context and relatedness o Care theory Relational Ethics o Ethical understandings are formed in, and emerge from, a person’s relationships with others o Four themes o Environment (health care system) o Embodiment (equal weight given to scientific knowledge and human compassion; to aim to become truly aware of what someone is feeling) o Mutuality (embracing the relationship between self+other as an opportunity for mutual benefit and developing new understandings) o Engagement (connecting with another person in an open, trusting, and responsive manner) ETHICAL DILEMMAS How is moral distress related to our values and beliefs? Ethical (or moral) dilemmas: Arise when there are equally compelling reasons for and against 2+ possible courses of action, and where choosing one course of action means that something else is relinquished or let go (CNA, 2017) Consider the principles of autonomy and beneficence as they relate to mandatory vaccination. Why/ how could an ethical/ moral dilemma lead to moral distress? • Example: Client wants to die at home. The nurse feels it will result in increased stress on a family with no resources. The nurse is being pressured to talk to family about discharge home because the hospital needs the bed for ER patients who have been in ER for a long time, and/ or patients coming out of surgery. Ethical dilemmas can cause moral distress for nurses, patients, and family members. CODE OF ETHICS o Statement of the ethical values of nurses and nurses’ commitments to persons with health care needs o Intended for nurses in all contexts o Provides guidance when nurses are working through an ethical challenge o Includes responsibility, accountability, and advocacy o Is to be used in conjunction with the professional standards, laws and regulations that guide practice o CNA Code of Ethics & CNO Code of Conduct o Posted on Brightspace CANADIAN NURSES ASSOCIATION (CNA) CODE OF ETHICS NURSING VALUES & ETHICAL RESPONSIBILITIES (7) o Provide safe, compassionate, competent, and ethical nursing care o Promoting health and wellbeing o Promoting and respecting informed decision-making o Preserving dignity o Maintaining privacy and confidentiality o Promoting justice o Being accountable Think of a recent interaction with a health care professional. Which of these 7 things did you value most in that interaction? What was most important to you? Which of these may have been challenged or questioned for you in a previous interaction with a HCP? COLLEGE OF NURSES OF ONTARIO (CNO) PRACTICE STANDARD: CODE OF CONDUCT PRINCIPLES (6) In the Code of Conduct, CNO (2023) has identified the following principles as being most important for nurses practicing in Ontario. Each are supported by statements of core behaviours nurses are responsible for: 1. Nurses respect client’s dignity. 2. Nurses provide inclusive and culturally safe care by practicing cultural humility. 3. Nurses provide safe and competent care. 4. Nurses work respectfully within the healthcare team to best meet clients’ needs 5. Nurses act with integrity in clients’ best interests. 6. Nurses maintain public confidence in the nursing profession. ETHICAL DECISION MAKING How will you make ethical decisions in your practice? What will be some challenges and barriers you will need to overcome? How will you overcome them and do what is right for your client(s)? What things will you base your decisions on? What will you try to put aside when making ethical decisions? Who can help you make ethical decisions? SUMMARY: APPLICATION EXERCISE With the classmates sitting beside you, come up with an ethical dilemma - it may even be something you’ve experienced in your life. It doesn’t need to be related to nursing. What personal values and beliefs are brought to the forefront for you? What ethical theories, principles, and concepts apply? How did/would you navigate the ethical dilemma? Consider implications of your decisions. NUSC 1P12: WEEK 6 PART 2: CHAPTER 10 LEGAL IMPLICATIONS IN NURSING PRACTICE (Potter et al., 2024) LEGAL CONTEXT Fiduciary relationship with patients o Meaning the ns-ct relationship is one in which the professional (ns) provides services that, by their nature, cause the recipient (ct) to trust in the specialized knowledge and integrity of the professional Sources of law o Constitution of Canada o Civil law (Quebec) and common law (rest of Canada) o Statute law o Federal, provincial, and territorial statutes o Created by elective legislative bodies (Parliament, provincial/territorial legislatures) o Precedent o Public law and private law Standards of care (CNO, employers, best practices, accountability of individual nurses to provide safe and competent care, policies and procedures) Professional regulation at the provincial or territorial level (The Nursing Act, 1991) & CNO) THE NURSING ACT (1991) & CNO o Provincial/territorial legislation grants authority to a nursing regulatory body (The Nursing Act, 1991) o Regulatory body is accountable to the public for ensuring safe, competent, and ethical nursing care (CNO) o Regulatory bodies exist for: o o o o Registered nurses Practical nurses Nurse practitioners Registered psychiatric nurses (some provinces) CNO PROFESSIONAL CONDUCT, MISCONDUCT DOCUMENT https://www.cno.org/globalassets/docs/ih/42007_misconduct.pdf “Acts that constitute a breach or abuse of the nurse- client relationship are considered professional misconduct, as is conduct that demonstrates a lack of integrity. In other words, a nurse’s conduct that is harmful in any way, or that undermines or detracts from the professional caring relationship with and for the client, is not consistent with expected professional standards” (CNO, 2019, p. 3) o Acts of professional misconduct may result in an investigation by the College, followed by disciplinary proceedings. o As set out in the legislation, the College investigates all complaints about nurses. o The College also receives mandatory reports of termination of nurses from employers. o When the information reported discloses reasonable and probable grounds to believe that the nurse has committed an act of professional misconduct or is incompetent, the executive director may initiate an investigation. LEGAL LIABILITY ISSUES IN NURSING PRACTICE: TORT LAW Unintentional Tort (negligence) o A civil wrong committed against a person or property o Wrong or injury a person suffers from someone else’s action o An act or omission causing unintended injury or harm to another person, usually negligence (unintentional tort), failure to provide good (standard) care, causing harm (med error), failure to foresee preventable harm Intentional Torts o Willful acts that violate a person’s rights o An act or omission causing intentional injury or harm to another person o E.g. breach of privacy/ confidentiality (incl. medical records, social media, disclosure/release of info), fraud, assault (physical or verbal threat), battery (intentional physical contact without consent), false imprisonment (threaten to or prevent from leaving an area), defamation (incl. social media), harassment, etc. INFORMED CONSENT A signed form is required for all routine treatment, all hazardous procedures, and some other treatments. ­ The person must have the legal and mental capacity to make a treatment decision. ­ The consent must be given voluntarily without coercion. ­ The person must understand the risks and benefits of the procedure or treatment, the risks of not undergoing the procedure or treatment, and any available alternatives. Provisions are made for deaf, illiterate, or foreign-language patients. CONSENT o Nurses have ethical and legal obligations for obtaining consent o Informed consent is entrenched in law and nursing standards o The Health Care Consent Act (HCCA) “…sets out explicit rules on when consent is required for treatment or admission to a care facility, and who can give the consent when the client is incapable of doing so” (CNO, 2017, p. 3) What circumstances could challenge ability to obtain consent? What influences someone's capacity to provide consent? CONSENT Major features of legislation 1. Health Care Consent Act (HCCA) o Promotes autonomy, facilitates communication o Deals with consent to treatment (treatment/intervention specific, ongoing process, emergency situations, assessing capacity), care facility and personal assistance 2. Substitute Decisions Act (SDA) o “The SDA deals with decision-making about personal care or property on behalf of incapable persons” (CNO, 2017, p. 4) INFORMED CONSENT (CNO, 2017, P.5) For consent to be “informed” the person must receive the information about the treatment that a reasonable person in the same circumstances would require to make a decision; and the person must receive responses to his/her requests for additional information about the treatment (opportunity to clarify and ask questions). The information given and received must include the: o o o o nature of the treatment (the “what”); expected benefits of the treatment (the “why”); risks and side effects of the treatment (the “what ifs” and “then what”) alternative courses of action (the “what else”; and likely consequences of not having the treatment (the what if I don’t) STEPS TO OBTAINING CONSENT 1. Assess capacity o To have capacity, client must be able to understand the information that is relevant to making a decision concerning the treatment, admission or personal assistance service; and appreciate the reasonably possible consequences of a decision or lack of a decision o Age of consent (no minimum age; HCP use judgement) Who assesses capacity? What if the client is deemed not to have capacity to make a decision? Is there a difference between surgery, admission to LTC, med admin, doing vitals, a dressing change, etc.? What if it’s an emergency situation? 2. If no capacity, inform the client that a SDM will make the decision o Identify SDM (based on HCCA hierarchy) o Obtain consent from SDM, advocate for client’s wishes to be respected and considered in all decisions CNO Practice Guideline: “Consent” http://www.cno.org/globalassets/docs/policy/41020_consent. pdf ABANDONMENT, ASSIGNMENT, AND CONTRACT ISSUES Short staffing: o Can cause legal problems to occur because of inadequate number of nurses to provide care o Abandonment Floating: o Based on census load and acuteness of patients’ conditions Physician’s orders: o Must be followed unless nurse believes an order is in error, violates agency policy, or is harmful to patients Contracts and employment agreements: o Nurses (and nursing students!) expected to perform competently, adhering to policies and procedures of agency CNO Refusing Assignments and Discontinuing Nursing Services LEGAL ISSUES IN NURSING PRACTICE: HOT TOPICS o Abortion o Drug regulations and nurses (controlled substances, prescribing, medical directives) o Communicable diseases (disclosure, contact tracing, reportable diseases, PPE for employees to prevent disease transmission, caring for clients with infectious diseases) o End-of-life issues and MAID (right to refuse life-prolonging treatment) o Advance directives (POA, substitute decision-makers, patient wishes) o Organ donation o Mental health crisis situations (keeping people safe but not using inappropriate restraints or false imprisonment) o Public health issues (enforcement of pandemic restrictions for ex.) o Staffing ratios (negligence, patient abandonment) o Harm reduction programs (overdose prevention/safe injection sites/street nursing) HOW DO NEW GRADS FEEL ABOUT THIS? “Reflecting back on my harm-reduction experiences, probably once a day, or sometimes multiple times, I think, “Am I doing the right thing as a nurse?” Because a lot of people think that we’re either enabling that behaviour or not taking that abstinence approach to specific things.” (Participant “Henry”) “Also, working short, there would be some nights where I would have nine to ten patients, and they’re all acutely sick. I would have some day shifts where I would have six to eight patients, and they’re all acutely sick. Having a maternity ward as well, well one room. I’d be sometimes the only RN on, you are the, I got to remember, head nurse, I guess. There are three birthing mothers, and where do you put them? There’s one room. Things like that, that’s a real challenge for someone new. It’s a good challenge, you gotta work as a team.” (Participant “Henry”) NURSES AND DRUG REGULATIONS Nurses are not legally entitled to prescribe medications. Nurses administer medications with physician’s/prescriber’s orders. Nurses (and nursing students!) o Must know the purpose, effect, potential adverse effects, and contraindications of any medication administered o Are responsible for questioning any prescriber’s orders that may be incorrect or unsafe o May be found negligent if they follow a prescriber’s order that is unclear or incorrect Journey to RN prescribing (cno.org) CNO PRACTICE STANDARD: CONFIDENTIALITY AND PRIVACY— PERSONAL HEALTH INFORMATION Nurses have ethical and legal responsibilities to maintain the confidentiality and privacy of client health information obtained while providing care. One way that nurses maintain boundaries and build nurse-client relationships based on trust is by respecting clients’ rights around confidentiality and privacy. Ontario’s privacy legislation supports and extends the College of Nurses of Ontario’s (CNO’s) standards on nurses’ accountabilities pertaining to clients’ personal health information. https://www.cno.org/globalassets/docs/prac/41069_privacy.pdf CNO PRACTICE STANDARD: CONFIDENTIALITY AND PRIVACY— PERSONAL HEALTH INFORMATION The Personal Health Information Protection Act, 2004 (PHIPA) o Governs health care information privacy in Ontario. o Information privacy is defined as the client’s right to control how his/her personal health information is collected, used and disclosed. o PHIPA sets consistent rules for the management of personal health information and outlines the client’s rights regarding his/her personal health information. o This legislation balances a client’s right to privacy with the need of individuals and organizations providing health care to access and share health information. o PHIPA permits the sharing of personal health information among health care team members to facilitate efficient and effective care.. CNO PRACTICE STANDARD: CONFIDENTIALITY AND PRIVACY— PERSONAL HEALTH INFORMATION The Personal Health Information Protection Act, 2004 (PHIPA) o “The Act also permits practitioners to disclose personal health information without obtaining consent in the following circumstances: o if disclosure is needed to provide health care, and consent cannot be obtained quickly; o to contact a relative or friend of an injured, incapacitated or ill client for consent; o to confirm that a client is a resident or client in a facility, provide his/her location and comment on his/her general health status (unless there is an express request not to do so); or o to eliminate or reduce a significant risk of harm to a person” (CNO, 2019, p. 7). NURSING STUDENTS & LEGAL LIABILITY o Students must know their own capabilities. o Students must separate their nursing student role from their work as unregulated care providers (if applicable). CNO Guidelines for the Learner o Recognizes their individual knowledge, skills and judgment, limits of responsibilities, and supervision requirements o Nursing students are accountable for their own actions to the patient, their educational institutions and placement organization. o Students are liable if their actions cause harm to patients, as is their instructor, the hospital, and the university.