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Nursing and You
Volume 2, No. 2, May 2000 - Pediatric Care
Working with Hope: A Primary Nurse at A Children’s Centre
Before she finished high school in her home town of Wiarton, Barb Bowman knew what she wanted to do for the rest of her life. As a candy-striper at the local hospital, she learned to love caring for people.
And before she completed her Registered Practical Nurse (RPN) program in Toronto, Barb already knew what kind of nursing it would be, and where. She was hired part-time at Bloorview Children’s Hospital (now Bloorview MacMillan Centre) while she was waiting to write her nursing exam, and 21 years later, she’s still there. Still there for the children.
Self-Regulation in Nursing:
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Bloorview has changed in many ways over the years. When Barb first worked there, it provided mainly residential care to children with a variety of disabilities. Now, it is a rehabilitation centre for patients transferred from other children’s hospitals across the province and beyond, including the Hospital for Sick Children in Toronto. Most of the children eventually go home after their stay at Bloorview.
"Kids stay from three to six months, sometimes longer," says Barb, "and often all or part of their families will stay here for a while as well. You get to know the clients very well, and that closeness is what I enjoy about the job. You come to identify a lot with the child’s struggle."
Unlike most hospitals, Bloorview MacMillan’s beds are pre-booked; nurses know in advance who’s coming, and the details of their condition. Nurses can request to be assigned as primary nurse or associate for a particular child; that client will then become a focus of her care until transition to the community.
"At Bloorview MacMillan RPNs are given a lot of responsibility on the care team," says Barb. "I’ve managed the care plan for a number of children and had abundant opportunities for both learning and teaching. I’ve also gotten involved in nursing research, and in a lot of workplace committees, advising on everything from budget to workload studies. It’s a great place to get involved in."
Barb gets very involved in her clients, too. An example is a baby boy, a premature twin who developed bleeding in the brain. His brother is healthy, but this boy has lost his co-ordination skills, and has feeding problems that will need to be sorted out before he goes home. Barb’s role will be to work with the team to help this child and his family adapt to their situation.
"Sometimes, despite all the odds, children do better than we expect. That’s what you hope for, that’s what you work for," Barb says.
As she speaks, Barb’s deeply caring nature shines through. That, no doubt, is why she’s been such a valued member of Bloorview MacMillan’s nursing team for more than two decades.
What is Nursing?
The goal of nursing is to restore, maintain and advance the health of individuals, groups or communities. It is both a "science" and an "art". The science is the application of nursing knowledge and the technical aspects of practice. The art is the establishment of a caring relationship through which the nurse applies nursing knowledge and uses judgement in a compassionate manner. Both focus on the whole person, not just a particular health problem.
Nurses can play many different roles – clinical practitioner, administrator, teacher, researcher – in many different settings – hospitals, long-term care facilities, patients’ homes, clinics, industry, or classrooms, to name just a few. They care for patients at all stages of the life cycle and in all states of health, from normal functioning to crisis.
In Ontario, the nursing profession is comprised of two categories governed by the College of Nurses of Ontario: Registered Nurses (RNs) and Registered Practical Nurses (RPNs); they are the only categories of health care provider entitled to call themselves "nurses". The two categories are subject to the same regulatory requirements; the general standards of practice, the complaints and discipline process, the registration process, all are the same. The major area of difference is in educational preparation, and because of this, in the scope of practice.
Editorial: Standards of Practice Ensure Quality Care
There are many ways in which the nursing profession regulates itself through the College of Nurses of Ontario (CNO) to protect the public. One of our most important obligations is to establish guidelines, or standards of practice, for how nurses do what they do, in an effective, safe and ethical manner.
There are two major components of these standards of practice for nursing. The first are legislation and regulations, laws which apply directly to nursing practice. Examples are the Regulated Health Professions Act, which identifies the controlled acts, such as injecting medications or putting instruments into the ear or throat, that nurses can perform (actions which, if performed by an unqualified person, could potentially harm a client), and the Nursing Act, which describes the practice of the profession. The regulations cover a variety of topics such as the requirements for registration, the quality assurance obligations of all nurses, and professional misconduct.
The standards of practice for nursing can also be found in a large number of documents called professional standards and guidelines. The focus of these can be broad, applying to all nurses in all health care delivery settings, or they can address a particular aspect of practice. Examples of the former are standards on ethics, nurses’ responsibility for ongoing learning, or how to maintain a therapeutic relationship with a client, while the latter include standards on footcare, transporting clients, or giving telephone advice. See the article on the restraints standard, on this page, for information on how standards are developed.
Standards of practice are never set in stone. Health care takes place in an environment of rapid change. CNO, as well as nurses and employers, monitor the standards to try to fit them to the reality of the workplace, and to ensure they continue to adequately safeguard the public.
That is the key - the public interest. The over-riding concern of every activity the CNO undertakes is that whenever a health care client encounters a nurse, the client receives the highest quality of care possible.
Mary MacLeod, RN
Council President, College of Nurses of Ontario
How Standards of Practice for Nursing are Developed
One of the College of Nurses of Ontario’s most important jobs is to establish standards for nurses to do what they do. Nurses are expected, in fact professionally accountable, to adhere to these standards of practice, and to maintain competent throughout their careers. But how do the standards come to be written? Who decides what nurses can or cannot, should or should not do?
In the case of legislation and regulations, the provincial government makes the final decision, but the College provides advice and recommendations. In regard to all other standards of practice, the profession is entirely self-regulating. Members of the profession are consulted extensively in drafting the standards, which are ultimately adopted by the College’s governing Council in an open meeting.
Steps in Developing Standards of Practice
- The need for a new standard, or the revision of an old one, is identified
through inquiries, complaints or other communication from nurses or
the general public. Emerging trends in the health care environment may
demand their development, for example, in areas like telephone practice
or complementary therapies. New or amended legislation may also compel
their revision.
- A literature survey, and consultation with experts and with other
jurisdictions, is carried out to see whether similar standards have
been developed elsewhere.
- A draft is developed, usually by the College’s own practice consultants
(all experienced nurses), with expert professional assistance if required.
- The draft is discussed by CNO’s governing Council, and changes
are made before entering into consultation.
- Extensive consultation is entered into with Ontario nurses, and sometimes
with employers, client groups, nursing organizations, and governmental
agencies. Up to 2,500 nurses may be consulted on one core standard through
focus groups, surveys and workshops. The standards may be revised extensively
as a result of the feedback obtained.
- A final draft of the standard is adopted by CNO Council, which includes
14 Registered Nurses, seven Registered Practical Nurses, and 18 representatives
of the general public.
A Standard on Using Restraints in Nursing
One of CNO’s more recent practice standards is the Guide for Nurses in the Use of Restraints, published in March of 2000.
Restraints are physical (e.g. jackets or bed rails), environmental (a secured unit), or chemical (behaviour-inhibiting medication) measures used to control the actions or behaviour of a client. What is considered a restraint may vary by practice setting; for instance, most paediatric nurses would not view a crib as a restraint.
Like many health care facilities in Ontario, the College supports a philosophy of least restraint. It is, however, recognized that in some situations, client needs may require behaviour management.
The purpose of the guide is to help nurses understand their responsibilities and make decisions regarding the use of restraints. For example, the guidelines will help them to minimize physical risks, to both the client and the nurse, while using least restraint, and give ideas on how to involve the client and his or her family in deciding which restraints might be appropriate.
Pat Morden, RN, CEO of Shalom Village, a nursing home in Hamilton, and also Vice-President of Resident Care with the Ontario Long-Term Care Association, played a large role in shaping the final version of the standard.
"The College sent us the original draft of the guide," she recalls, "and we had an opportunity for review and input, particularly related to the principle that restraints should only be used as an intervention of last resort. We were invited to sit down with the College’s practice consultants and discuss the content and some changes."
Pat says the consultation process for nursing standards is very important. "This is an area where long-term care nurses have a lot to offer; we were able to contribute some realistic scenarios to the document. Even 15 years ago, we didn’t have the knowledge or understanding required to avoid restraining a client. But we’ve learned a lot. This kind of consultation is essential to keep regulation current."
Promotion and Prevention: The Changing Role of the Camp Nurse
When someone has a wealth of expertise in a subject, we might say they "wrote the book" on it. In referring to Waterloo RN Mary Casey and camp nursing, we’d be right.
Mary first started work as a camp nurse at a Canadian Girls In Training camp in the 1950s. For the last 22 years, she’s been the health care coordinator at Camp Big Canoe, a popular United Church facility on Hart Lake in the Muskokas. She’s seen a lot of changes in those years.
"We used to be seen as not much more than first-aiders," she recalls. "Now, illness and injury prevention are more the focus. We monitor the cleanliness of the cabins, the washrooms, the kitchens. We do health assessments on everyone, campers, counsellors and kitchen staff, within a couple of hours of their arrival at camp, and safety and hygiene are emphasized in every activity – even though it’s summer, for instance, sandals are discouraged."
One of the major problems with camp nursing is inconsistency, not just from camp to camp, but from week to week at a particular camp; most camp nurses are volunteers, and few can attend a camp for the whole summer. That inconsistency inspired Mary to write her book Camp Health Care; it also compelled the College of Nurses of Ontario in 1990 to develop its own Guidelines for Camp Nursing for all Ontario nurses to follow (updated in 1999 with Mary’s help). They provide guidance in such areas as medication administration, record-keeping, obtaining consent and liability protection.
"Nurses now have their own committee within the Ontario Camping Association," says Mary, "and we’ve promoted professionalism of our nurses through workshops. If you love the outdoors (nurses are encouraged to participate as much as possible), and if you love watching kids grow (we often see the same children year after year), being a camp nurse can be a lot of fun. But it’s also a very independent role, and when you’re isolated, the health issues can get pretty intense, everything from severe allergic reactions to bumps on the head. You’re on call 24 hours a day, and believe me, it’s no holiday."
Most summer camps place great importance on early communication with parents to minimize the health risks to their kids during the time they’re away. After all, parents are placing a high amount of trust in people they don’t know very well. Thanks to nurses like Mary Casey, and the vigilance of the College of Nurses of Ontario, they can feel confident that their trust is well-founded.
Healthy Babies, Healthy Children
The nurses who work for Ontario’s 37 public health units are dedicated to the old health care axiom, "an ounce of prevention is worth a pound of cure". They spend very little of their time treating clients; most of their programs are aimed at educating the public about how to become and stay healthy, or at promoting health through influencing public policy and community development (such as advocating for no-smoking bylaws in public places).
Using Nursing Standards in "Healthy Babies"Public health nurses like Jane Hess often consult CNO standards when working with children and parents. The College’s Guide to Nurses for Providing Culturally Sensitive Care is one example. "People often equate culture with ethnicity," says Jane, "and we don’t have a big variety of ethnic groups in these counties. But a lot of people live in isolated rural areas, and they have diverse perceptions and values about health care. These are cultural challenges." The "Healthy Babies, Healthy Children" program also makes
extensive use of lay home visitors who, unlike nurses, are unregulated
by the province. In this case, the College’s Guidelines for
Working with Unregulated Care Providers is an excellent resource.
It provides direction in such areas as teaching, supervising or
delegating to unregulated providers.
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For perhaps no other sector of the population is health promotion more important than pre-school-age children. This is the reason for a program introduced two years ago by the province, called "Healthy Babies, Healthy Children". Registered Nurse Jane Hess coordinates the program for the Leeds, Grenville and Lanark District Health Unit in Brockville.
"The idea is to give kids as strong a start in life as possible," says Jane. "We have over 1,700 births a year in this district, and a quarter of those already show some risk of future health problems when they’re born, either because of family history, socio-economic environment, or the condition of the child itself (such as a deformity or respiratory problem).
Their moms and dads, particularly if it’s the first child, need a lot of support. They have a million questions, about what to feed their kids, or what to look for to head off an illness, and generally how to foster healthy growth and development. We’re there to make sure those questions are answered."
There are some classes and group programs, but the bulk of the Healthy Babies program is home-based. It begins within 48 hours of the baby and her mother being discharged from hospital, and may continue for those in need until age six.
The home visits decrease as parents become more confident, and the monitoring is often turned over toa lay home visitor, a non-nurse who will consult with the public health nurses on an ongoing basis.
"If we put a lot of money into those first six years," says Jane, "we know that the burden on the health care system in later years will be reduced.
It’s a product of a whole lot of little changes, and we can easily see that we’re making a difference. I’ve spent my whole nursing career in maternity and paediatrics, and I love children. To have such a positive impact on their health is very gratifying."
Crossing the Boundaries in the Nurse-Client Relationship
From time to time, concerns may arise about a nurse’s conduct or competence. A key element of the College of Nurses of Ontario’s responsibility is to investigate all written complaints received about a nurse, from clients, employers, fellow nurses or members of the public. The following is a fictional scenario based on recent cases that have come to the College.
A nurse was working with a disabled child who required constant nursing attention. He was a 13-year-old, in a wheelchair, lived at home, and attended a public school and programs at a centre for disabled children. He was able to speak and was alert, though his level of comprehension was below normal for his age.
He became aware of a camp program that he could attend full-time in the summer, a residential camp for disabled children, that provided full nursing care. He would be involved in educational and recreational activities. His social worker at the children’s centre encouraged him to go, because it could increase his independence and self-esteem.
The nurse was very involved with this client; she was his primary care-giver. She criticized other nurses who worked with him when she was not present. She made comments to the child about him being her favourite patient and that they had a "special relationship". She frequently brought him gifts, and visited his home even when she wasn’t scheduled to work. Her over-involvement was noticed by the other nurses and her nurse manager. When people spoke to her about it, she became defensive.
The incident that brought her behaviour to the attention of the College concerned the camping opportunity. If the boy went to camp, the nurse would not have work for the two summer months he would be away. This would adversely affect her income. She mentioned this to the child, and in doing so suggested that he would not like the camp, that he would be homesick, that he was not ready for so much independence, and that she wanted to continue to look after him because she needed the money, but also because she would miss him.
The boy told his parents he was thinking about not going to the camp, and after some prodding told them what the nurse had said to him. The parents reported this to the nurse’s employer. The nurse was dismissed, and a complaint registered with the College of Nurses (mandatory reporting of terminations by an employer is one way CNO receives complaints).
After an investigation into the matter, it was found that the nurse had crossed the bounds of the therapeutic nurse-client relationship. The nurse received a letter of caution, and was also given an oral caution by the College’s Complaints Committee (which consists of nurses as well as representatives of the public). The committee did not order a disciplinary hearing, deciding it would be too traumatic for the client to have to testify. The nurse also signed an agreement to take a course in ethics.
In the nurse/client relationship, the client’s needs are the sole concern. In this case, the nurse put her own needs ahead of the client’s best interests.
The Nurse and the Client: What You Should Expect
How should a nurse relate to a client? What does a client have a right to expect (or not to expect) from a nurse? We use the term "client" rather than "patient" to signify that the person receiving nursing care is in fact a customer whose rights and wellbeing must always be of prime concern.
The principles guiding this relationship can be found in the College of Nurses of Ontario’s Standard for the Therapeutic Nurse-Client Relationship, a practice guide that all Ontario nurses are expected to know and follow.
Aspects of the Nurse-Client Relationship
The authority of the nurse’s position in the health care system, her or his specialized knowledge, influence with other health care providers or the client’s family, and access to privileged information – all these factors put the nurse in a position of power. The nurse must use this power in a caring manner to ensure the client’s vulnerable position is not taken advantage of.
The client expects the nurse to possess knowledge and skill and to demonstrate caring attitudes and behaviour, and so entrusts his or her care to the nurse. If trust is breached, it is very difficult to re-establish.
Respect for the dignity and worth of the client is also crucial to an effective relationship. The nurse needs to know and understand the culture and other aspects of the client’s individuality, and to take these into account when providing service.
By virtue of the kinds of activities nurses perform for and with clients, there is intimacy in the relationship, with personal and private closeness on many levels. The nurse must be careful to ensure this intimacy does not jeopardize the therapeutic nature of the relationship. The client’s needs are of utmost importance; the needs of the nurse must never interfere.
Warning Signs
There are a number of warning signs that may indicate a nurse is in danger of crossing the appropriate boundaries of the nurse-client relationship. These may involve treating a client differently from others: spending extra time with the client, dressing differently for that client, spending off duty time with that client, or keeping secrets with the client apart from the rest of the health team.
Client Advocacy – An Important Role for Nurses
Judy Mayer is an RN with Interlink, a non-profit agency which helps cancer patients and their families in many parts of Ontario with home visits by specialized cancer nurses. Judy lives in Sudbury, but is responsible for an incredible 300,000-square-kilometre area. That takes dedication.
"I’ve been in paediatrics all my nursing life," says Judy, "and in paediatric oncology (cancer care) for most of it. Interlink is an opportunity to work with clients and their families beyond the walls of the clinic or hospital."
In her work Judy often finds the need to advocate, with her colleagues or with other agencies, on behalf of her clients. In fact, in the College of Nurses’ Ethical Framework for Nurses, the role of client advocate is seen as an integral part of nursing practice.
"Cancer patients, especially children and their families, are very vulnerable, in a state of shock and stress, particularly after the diagnosis first hits them. Part of my job is to guide them in those first few weeks, to empower them to ask the questions they need answered. They have to understand all the options available in their plan of care, and I’m by their side to make sure the system is responsive to their needs."
An excellent example is the provincial program for travel grants to families in northern Ontario who must take children to distant cities for treatment. Before long in her present job, Judy began to feel that there was too much red tape for these families, especially those who must travel frequently ("they have bigger things to deal with"). She spoke up on behalf of her clients, and the process was simplified.
Nursing isn’t just dressing a wound or handing out a pill. It’s doing what’s best for the health of the client and his or her family, and sometimes that requires the voice instead of the hand.
Reflections: A Family’s Experiences with Nurses
Often for nurses, the "client" is more than an individual patient, but the patient’s family, friends, even the surrounding community. The following family is an example.
Bill and Ruth Douma run a market farm in the Ottawa Valley near Beachburg, about halfway between Renfrew and Pembroke, Ontario. They grow strawberries, raspberries, rutabagas, squash and pumpkins. They’ve also nurtured three children – Gerald, 12, Hermina, 13 and Maria, 16. Until a few years ago, the Doumas were a normally healthy lot – the odd sniffle, a rare fracture, and that was about it.
Then, when she was 13, Maria suddenly contracted a very dangerous disease; she nearly died before a young doctor at the Children’s Hospital of Eastern Ontario (CHEO) realized what it was. Wegener’s granulomatosis is an auto-immune disease in which the body attacks the soft organs. Maria is one of only six Canadian children with the condition, and she’d already lost both her kidneys and part of her liver and both lungs before she was diagnosed.
Maria spent over seven months at CHEO that time. She returns for regular checkups, as well as going to the dialysis unit at Renfrew Victoria Hospital three times a week. She is anxiously awaiting the go-ahead for a kidney transplant (many members of her immediate and extended family have volunteered as donors).
Maria has had abundant experiences with nurses. And so have her parents and all of her family. These are some of their thoughts on those encounters.
"At Renfrew, it’s a nurse who takes charge of Maria’s dialysis. She’s very conscientious about keeping on top of her condition, phoning CHEO in Ottawa if there are ever any doubts." – Bill
"I think nurses in this part of the country have been undervalued for what they know. But that’s changing, I hope. Nurses aren’t afraid to speak up on the part of the patient." – Bill
"I think one nurse – I don’t even know her name – made the difference between Maria living and dying. At the hospital, the first night, she was expected to die, and she didn’t. The same the next night. Finally this nurse said, ‘Look how hard this girl is fighting… don’t you think we should be fighting a little harder, too?’ " – Bill
"The nurses have been fantastic with Maria, with all of us. They’re so patient, they’ll go over something with you as long as it takes for you to understand. At CHEO, Maria was there over Christmas, and they set up the whole room for a Christmas party – a tree, presents, everything. I stayed in the hospital for quite a while with Maria, and one of the nurses brought me her Bible from home. She knew how important it was to us." – Ruth
"Once I was supposed to go into a meeting with all of Maria’s team. I was nervous, so I bounced some of my questions off the head nurse to see if they made sense. When I got in there, I forgot some of them, and she reminded me – she’d written them all down after I talked to her. That kind of detail, that’s what is so important." –– Bill
"When it comes down to it, nurses have made the difference between us falling part, and the way it’s turned out. They’ve meant a lot to us." – Bill
What is the College of Nurses of Ontario?
The College of Nurses of Ontario (CNO) is the regulatory body for nursing in this province. Established by, but at arm’s length from, the provincial government, CNO derives its revenues from annual membership fees; it receives no funding from the province. The College decides the criteria for becoming a nurse in Ontario, and the standards of practice to be met to maintain that designation and privilege. No one can practise as a nurse in Ontario, or use the titles "nurse", "registered nurse", or "registered practical nurse", without a valid certificate of registration from the College.
Contact Us
For further information about any aspect of nursing regulation in Ontario, including how to express a concern about a nurse's conduct or practice, please contact:
College of Nurses of Ontario
101 Davenport Road
Toronto, Ontario, M5R 3P1
cno@cnomail.org
Telephone: 416-928-0900 or Toll Free 1-800-387-5526
Fax: 416-928-9841
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