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Quality Practice

Summer 2003 - Vol. 2, No. 3

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Abandonment: Clarifying the issue

During stressful situations, such as SARS, misconceptions often arise regarding regulatory issues that are dealt with by the College of Nurses of Ontario, and labour issues.

One such issue is the difference between refusing an assignment and abandoning a client. To support their nurses and allay fears surrounding professional misconduct allegations, employers must understand the difference between the two situations.

Refusing an assignment

Nurses have the right to refuse assignments that they believe will put them or their clients at risk. However, nurses should have a justifiable rationale for their refusal.

Nurses must inform employers why they are refusing the assignment (e.g., the facility does not have the equipment that would ensure the nurse's safety). The College recommends that nurses document all the steps they took prior to refusing the assignment.

Assignment conflicts between employers and nurses are labour relation issues and rarely involve the College. These labour issues are usually settled among the employer, their employees and the employee's union, if necessary.

Abandoning a client

The difference between refusing a particular assignment and abandoning a client lies in the fact that, in the case of abandonment, the nurse has already been assigned the client and has accepted that assignment. Abandonment occurs when the nurse who accepted the assignment:

  • discontinues care without the client's permission;
  • does not arrange for suitable alternative or replacement care services; or
  • does not allow the client a reasonable opportunity to arrange for alternative or replacement services.

Although the College rarely receives reports of nurses abandoning clients, nurses who do stop providing care under one of these three circumstances may have committed professional misconduct. The College deals with such reports on a case-by-case basis.

For additional clarification about refusing an assignment or abandonment, please visit www.cno.org, or call CNO at 416-928-0900 or toll-free in Ontario 1-800-387-5526.

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New legislation affects RN(EC) practice

Amendments to the following nursing regulations will affect RN(EC) scope of practice: Public Hospitals Act (Regulation 965), Health Insurance Act (Regulation 552), Nursing Homes Act (Regulation 832), Charitable Institutions Act (Regulation 69), and Homes for the Aged and Rest Homes Act (Regulation 637). Amendments to the last three statutes also gives RPNs authorization to access and administer drugs within their scope of practice. For more information, see Communiqué, June 2003 or visit www.cno.org.

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Reducing client abuse: A role for nurse administrators

Employers and nursing administrators have an important role in helping nurses prevent client abuse, especially in high-risk areas where abuse is more likely to happen. Early intervention is the key to preventing inappropriate behaviour by nurses or their clients.

Abuse can be subtle or overt and always negatively impacts client outcomes. Awareness is the first step in abuse prevention. Client abuse is defined as a misuse of power or a betrayal of trust, respect and intimacy in the nurse-client relationship. There are six forms of abuse: physical, verbal, emotional, sexual, financial and neglect.

Although abuse can occur anywhere, CNO's statistics show that abuse happens more often in long-term care and psychiatric facilities. Elderly women and those who are in poor physical or mental health make up the majority of abuse victims.

Regardless of the situation, nurses are accountable for the care they provide. By implementing systems and mechanisms that support professional nursing practice and reduce stressful triggers, employers can help nurses better manage challenging client behaviour and stressful situations, and ultimately improve client satisfaction.

Look for Triggers

Education is an important tool in preventing abuse. Nurses need to learn about client abuse, what it is and why it happens, the warning signs and the triggers that can lead to abuse.

Some facilities have in-house abuse prevention programs, which should be routinely reviewed by staff to encourage vigilance. Ensuring nurses understand the dynamics of the therapeutic nurse-client relationship is key to promoting good nursing practice and reducing client abuse.

Although awareness and education are key in reducing or eliminating abuse, support systems for nurses are also important. Open communication between staff and management is needed if nurses are to feel comfortable asking for help. When a situation is too difficult to handle alone, nurses need to feel that they can consult with their managers and supervisors for support and guidance without feeling inadequate or incompetent.

Sometimes nurses simply need to vent their frustrations. Create activities where nurses can feel free to identify stressors or issues which can diffuse stress and encourage problem solving.

To aid in abuse prevention, CNO has developed a program called One is One Too Many. It's designed to educate nurses and administrators about recognizing, preventing and stopping client abuse. The program contains learning modules on the therapeutic nurse-client relationship and recognizing forms abuse. It also empowers nurses to act when they witness client abuse. A teaching video features dramatizations of real cases and nurses talking about their experiences. The workbook is a self-directed learning tool containing exercises and scenarios to help nurses develop strategies to prevent abuse.

The One is One Too Many program can be easily implemented in a variety of ways from individual self-study to staff lunch and learn sessions. If you already have our program, consider holding refresher sessions.

Supporting Nurses

Employers need to build quality practice settings that support professional practice. CNO has developed the evidenced-based Practice Setting Consultation Program® (PSCP®) that helps employers reflect on their current systems in the areas of care delivery processes, communication, leadership, professional development and organizational supports. (For more information, see page 3.)

Preventing abuse is more than an individual effort. Together, nurses and employers can implement the necessary tools and mechanisms needed to recognize and prevent client abuse. By creating supportive environments, employers can assist nurses in effectively managing challenging behavior clients and significantly reduce incidents of abuse.

For more information on the One is One Too Many abuse prevention program or PSCP, please visit www.cno.org, e-mail cno@cnomail.org or by phone 416-928-0900, toll-free in Ontario 1-800-387-5526, ext. 6305.

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Helping staff manage challenging client behaviour

To help staff manage challenging client behaviour, employers need to build quality practice settings that support professional practice. The following tips are based on CNO's Quality Practice Settings Attributes Model©.

Care Delivery Processes:

  • Develop a consistent team-based plan for assessing (understanding the behaviour) and managing challenging behaviour.
  • Institute regular rounds to measure plan effectiveness.
  • Implement a staffing mechanism that ensures the right mix of competent and experienced staff to execute the plan.

Communication Systems:

  • Implement a critical incident debriefing process that listens to staff concerns and acts on their suggestions for improvements.

Facilities and Equipment:

  • Ensure access to emergency call equipment (e.g., cell phones, alarm buttons) for prompt assistance to protect the client, staff or other clients.

Leadership:

  • Empower staff to make appropriate assessments and initiate team-based care planning.
  • Implement strategies that utilize staff expertise and support staff decisions for implementing and managing care.

Organizational Supports:

  • Encourage incident reporting and link it with quality improvement and risk management strategies.

Professional Development Systems:

  • Implement in-house continuing education in holistic and focused psychosocial assessment, conflict resolution and self-defence skills.
  • Implement access mechanisms to clinical education resources (e.g., journals, web, nursing experts) so that practice concerning challenging behaviour management reflects best practice guidelines.

For more information, visit www.cno.org, e-mail cno@cnomail.org or contact Employer Support Services toll-free in Ontario 1-800-387-5526 or 416-928-0900, ext. 6305.

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Best practices in disclosing health care errors

How a facility deals with a health care error can either exacerbate an already painful incident or, through disclosure, promote openness, healing, learning and prevention. According to research by the Institute for Safe Medication Practices (ISMP) Canada, Healthcare Papers and the Royal College of Physicians and Surgeons of Canada, open disclosure is the most effective way to deal with an error. Use the following tips to help staff manage these situations. For more detailed information on these tips, see Communiqué, June 2003 or find more resources in the Special Notices section of the website.

  1. Be prepared! Have disclosure policies and procedures in place.
  2. Have a key contact person or team ready to help staff deal with adverse events.
  3. Disclose to the client or family as soon as possible.
  4. Choose an appropriate setting.
  5. Acknowledge that a mistake has been made.
  6. Describe the course of events.
  7. State the nature of the mistake, consequences and corrective action.
  8. Express regret and apologize, if appropriate.
  9. Elicit questions or concerns and commit to addressing them.
  10. Provide follow-up to the client.
  11. Provide personal and professional support, and guidance to staff.
  12. Learn what happened! Use an open approach to identify causes.
  13. Communicate the incident to ISMP Canada's Medication Errors Reporting Program.

Resources for Employers

ISMP Canada has many resources available for health care professionals at www.ismp-canada.org.

In 2002, the National Steering Committee on Patient Safety released Building a Safer System: A National Integrated Strategy for Improving Patient Care (see www.rcpsc. medical.org), which lead to a national study on the extent of adverse events in the Canadian health care system. The Canadian Adverse Events Study (see http://secure.cihi.ca) run jointly by the Canadian Institute for Health Information (CIHI) and the Canadian Institutes of Health Research (CIHR), will be released in 2004. However, a number of recommendations for designing safer systems entitled Making Patients Safer! Reducing Error in Canadian Healthcare are already available at www.longwoods.com/hp/ index.html.

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Hiring nursing students as UCPs

Employers routinely hire nursing students as unregulated care providers (UCPs) because students are considered capable and knowledgeable providers of personal care. Before hiring students, employers may want to review nursing legislation and CNO standards to ensure the students are appropriately utilized.

Since the title "nurse" is protected, nursing students cannot hold job titles such as nursing aide, student nurse or nursing assistant. However, students may use titles such as health care assistants, personal support workers or care attendants. Students can only use the title "student nurse" during clinical placements associated with their basic nursing education program.

Existing legislation does not allow UCPs or nursing students to perform controlled acts unless the authority has been formally delegated to them by a Registered Nurse. For strategies to support professional practice for nurses working with UCPs and information on UCPs and controlled acts, employers can consult CNO's Utilization of Unregulated Care Providers (UCPs): A Guide to Making Decisions.

Employers should consider the appropriateness of delegating controlled acts to nursing students working in UCP roles given their limited exposure in the practice environment and limited opportunity to maintain competence. CNO's document The Regulated Health Professions Act, Part B: Scope of Practice and Controlled Acts Model, explains delegation accountabilities.

For more information, visit www.cno.org, e-mail cno@cnomail.org or phone Employer Support Services at 416-928-0900 or toll-free in Ontario 1-800-387-5526 ext. 6305.

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Ask CNO: "Are you witnessing consent?"

Q:I often ask nurses to witness a signature from a client (or their substitute) for the purpose of obtaining consent for a procedure. Consent signatures are required for all procedures. Nurses claim that they are accountable for obtaining informed consent, not just a signature. Are they correct? Are nurses accountable for determining if the client has been fully informed?

A:Yes. The most important part of the consent process is ensuring that the client is informed. A client's signature is meaningless if the client has not been fully informed. Some employers require nurses to obtain the client's signature on consent forms as part of their role and have told staff that they are only witnessing the signature and not verifying that informed consent has been obtained. However, nurses have ethical and professional accountabilities to ensure the client is fully informed and capable of giving consent.

Accordingly, it is important that nurses ask clients if they understand what it is they are consenting to and if all of their questions have been answered. In any situation where the nurse believes the client has less than full understanding of the proposed treatment, the nurse has a professional obligation to act as a client advocate and ensure that the client receives the necessary information.

Agency policies do not override a nurse's professional accountability. Furthermore, nurses are accountable for advocating for processes that enable them to practice in accordance to CNO standards. If the witness is acting in a "clerical capacity" by seeking only the signature, then perhaps support staff, such as a ward clerk, could carry out this function.

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Web Updates

Visit www.cno.org for the latest College news

In praise of nurses

During nursing week, CNO ran an ad praising nurses who are on the front lines of the recent SARS crisis. Nurses have demonstrated professional competence and dedication throughout this challenging and frightening situation.

Guide for internationally nurses

The Registration Guide for Internationally Educated Nurses is now available. The interactive guide details the nursing registration requirements and processes in that ensures nurses have the skills and competencies to provide safe, effective care to the public.

Disciplinary decisions online

Full-text decisions made by the Discipline Committee will be available by July 31, 2003.

New Med Standards online

The new Medication Standards (Revised 2003) is now online. For a printed version (cost $3.50) call Customer Service at 416-928-0900 or toll-free in Ontario 1-800-387-5526.

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