Class1 history, code of ethic, cultural safety

history1 : 460-370

revolutionized medcine by establish medcine practice, do not harm

history 1750 bc sode of hammurubi

briong rule pf rightness destory devil, include how dr should treat pt

hx 304 322 aristotle

virtue central to leding to good life-basic of virtue ethic

hx 1748 heremy and utilirianism

operate under that the right pr ethic choice lead to greatest happiness for greatest number of pp,

hx 1785 immnueal kant denotlogy

dentology does not look at consequence of action, but more at action

hx1914 schloendorff

earlier nyc case of informed consent, scholednroff not giving consent to amputate arm, adult have right to determine what should be done to their own body

hx 1976 tarasoff regent usc

mental health profession have duty to warn individual who are being thrated with body harm

1979 biomedical ethic principle and beauchamp

first bioemdical ethic : autonomy,benficience, non maleficence and justic

1980 chambliss nursing stufy

nurse ethical dimelmma cause by rganization and nurse central place, heirachy of ;ower and slow pace of system change

concept of relationality

 relationality posits that individuals do not exist as isolated, autonomous units

identity, health, and healing are co-created through an ongoing web of relationships: person-to-person, person-to-community, and person-to-environment.

Relation to the "Other":

pt not as objective/case/problem to be solved

• equires ethical attunement, active listening, and recognizing the shared humanity and agency of the other person.

Relational Accountability

• morally accountable not just for outcomes, but to the relationships they cultivate with patients, families, and communities.

6r framework

Kirkness & Barnhardt)

Indigenous and relational care models, the Six Rs govern ethical practice and community engagemen

respect

relevance

responsibility

reciprocity

represenation

relationship

6r respect

• Upholding the inherent dignity, autonomy, cultural integrity, and worldview of the other person.

• Refusing paternalistic approaches by honoring the individual's lived experience and self-determination.

6r relevance

• Ensuring care plans, interventions, and research align with the real-life priorities, needs, and cultural context of the person and their community.

• Avoiding generic, externally imposed solutions that do not fit the patient’s lived reality.

6r responsility

• Ethical accountability for the trust and stories shared by the patient or community.

• Recognizing the practitioner's duty to advocate, prevent harm, and follow through on commitments.

6r reciprocity

• Rejecting one-way, transactional interactions in favor of bidirectional learning and exchange.

• Acknowledging that both caregiver and patient contribute valuable knowledge, insights, and gifts to the healing process.

6r represenational

• Ensuring the patient's voice, values, and community context are authentically integrated into decision-making and systemic policies.

• Preventing stereotyping, erasure, or speaking over the person.

6r relationship

• on binding all principles together.

• Building an authentic therapeutic alliance grounded in continuity, sustained trust, presence, and mutual safety.

nursing ehtic central purpose

navigate the moral and legal landscape of practice

understand core theoretical frameworks

build the moral courage required to address ethical dilemmas in complex clinical environments.

situating ethics

• Nursing is fundamentally a moral endeavour; nurses occupy unique "in-between" positions where systemic demands conflict with bedside patient needs.

Ethical Theories & Principlism

• Contrasts duty-based ethics (deontology) with outcome-based ethics (utilitarianism/consequentialism), bridging them through the four principles: autonomy, beneficence, nonmaleficence, and justice.

Professional Codes of Ethics

• CNA) Code of Ethics outlines professional values and duties.

• not enforced by public courts

• it sets enforceable standards of conduct governed by provincial regulation.

Ethics vs. The Law

• Institutional constraints, understaffing, and power imbalances produce moral distress (knowing the right action but being unable to act)

• and cumulative moral residue (long-term harm from chronic compromises).

What is meant by nurses occupying "in-between" spaces?

sit directly between patients/families, physicians, interprofessional colleagues, and institutional management.

Constant proximity: Because nurses remain at the bedside around the clock, they witness everything

Competing demands: caught between institutional efficiency and their fundamental duty to advocate for the individual patient's dignity, comfort, and safety.

How can you describe your nursing practice as a moral endeavour?

• Inherent vulnerability:involves intimate bodily contact, human suffering, and profound power differentials, meaning technical actions are never purely mechanical

• Everyday ethical choices: Everyday nursing decisions carry moral weight, such as prioritizing , maintaining physical privacy during procedures, or validating

• Commitment to human good: Practice is driven by core values—human dignity, equity, relational trust, and advocacy—rather than institutional convenience.

dentology-duy based core premise

Actions are intrinsically right or wrong based on duties, rules, and universal moral obligations, regardless of consequences.

denotolgy guiding rule

Act only according to rules you would want universalized; treat individuals as ends in themselves, never merely as means.

dentology clinical application

Truth-telling and upholding informed consent are absolute duties, even if disclosing a diagnosis causes emotional distress.

dentology critique

• Rigid and inflexible when duties conflict

• Often discounts the emotional, relational, and contextual reality of complex human scenarios.

Consequentialism / Utilitarianism core premise

Actions are judged morally right or wrong entirely by their outcomes or consequences.

Consequentialism / Utilitarianism guiding urle

Maximize the greatest good, benefit, or happiness for the greatest number of people (utility).

Consequentialism / Utilitarianism; clinical application

Triaging limited emergency resources or ICU beds during a pandemic crisis to save the maximum number of life-years.

Consequentialism / Utilitarianism crtiqiue

• Can justify violating individual rights, autonomy, or minority interests to serve the benefit of the majority.

• Predicting all short- and long-term consequences in unpredictable clinical situations is practically impossible.

crtique of principlism

• Although designed to bridge these theories using four principles (autonomy, beneficence, nonmaleficence, justice), learners often apply it mechanistically and rigidly.

• It reflects a heavily Westernized bioethics perspective and can fall short when applied to collectivist or Indigenous relational worldviews.

law

• The external, enforceable baseline of acceptable conduct required by society.

• Focuses on minimum standards, liability, and regulatory compliance, enforced by courts and legal statutes.

• What is legal may not be ethical

• What is illegal may be ethically defensible in emergencies

• Creates legal reporting duties that can conflict with therapeutic trust and confidentiality.

ethics

• Represents an internal commitment to doing what is right, just, and good.

• Operates well above the legal floor, guiding clinical advocacy, relationship building, and compassionate care.

• Professional Codes of Ethics are enforced through internal regulatory discipline committees rather than public courts.

what does moral integrity look like in a nursing workplace?

1. Moral Autonomy: Developing, owning, and critically examining one's authentic values rather than passively adopting institutional norms.

2. Fidelity to Promise: Making commitments to patients and colleagues and reliably following through, establishing trust.

3. Steadfastness: Standing firm for ethical values in the face of pressure, institutional pushback, or personal risk

4. Wholeness: Maintaining moral consistency across all personal and professional roles, avoiding hypocrisy.

• actively addressing the sources of moral distress and preventing the accumulation of moral residue.

How personal values align with ethical leadership and moral integrity:

• Ethical Leadership as a Moral Compass: leaders use their position and knowledge as a positive force to create safe, open practice environments where staff do not feel silenced.

• Cultivating Moral Courage: willingness to advocate for what is right despite fear, adversity, and institutional pressure. It bridges the gap between moral intent and clinical action.

• Practical Alignment: Aligning personal values requires active reflection, knowing personal limits, speaking up when safety or dignity is compromised, and fostering a workplace culture grounded in safety and mutual respect.

What a Code of Ethics Typically Contains

• Core Values & Ethical Responsibilities: Fundamental commitments of the profession

• Standards of Professional Conduct: Clear guidelines governing therapeutic boundaries, conflicts of interest, competence, and accountability.

• Relations with the Public, Clients, and Colleagues: Obligations regarding interprofessional collaboration, reporting unsafe practice, and maintaining the public trust.

• Framework for Ethical Decision-Making: Guidance for resolving conflicts, navigating moral distress, and balancing competing priorities

Relationship Between Professional Codes of Ethics and the Law

• The Law as the Floor: The law establishes the minimum standard of acceptable societal conduct. Violations can lead to civil, criminal, or regulatory prosecution.

• Ethics as the Professional Standard: Codes of ethics articulated by professional bodies set higher moral ideals, guiding clinicians toward optimal care.

• Legal Weight of the Code (Quebec Context): The OIIQ official provincial regulation under the Professional Code. A breach of the code is not merely a theoretical failure; it constitutes professional misconduct subject to formal disciplinary action

How the Codes Inform Daily Practice & Bedside Experience

• Promoting Safe, Competent, and Ethical Care:

  • Identifying personal practice boundaries and refusing tasks all outside authorization.

  • Ensuring medication reconciliation, double-checking , and speaking up about near-misses.

• Promoting and Respecting Informed Decision-Making:

  • Ensuring the patient clearly understands procedures before proceeding.

  • Respecting a capable adult's right to refuse treatment

• Honoring Dignity and Privacy:

  • Pulling curtains, keeping bodies covered e, and maintaining professional decorum at all times.

  • Guarding personal health information by not discussing patient cases in public

• Maintaining Professional Integrity & Boundaries:

  • Declining personal gifts

  • Refusing dual relationships or personal social media interactions with current or recent patients.

Clinical Competence and Unsafe Assignments

• OIIQ Code (Article 44 / 45): A nurse must not demonstrate negligence in care and treatments, must perform required clinical evaluation, and must maintain clinical competence.
  OIIQ

• CNA Value (Providing Safe, Compassionate, Competent, and Ethical Care): Mandates that the nurse practice within the boundaries of their individual competence. The nurse has an ethical and legal obligation to formally inform the charge nurse of their lack of certification, negotiate a safe realignment of duties, document the staffing concern objectively, and refuse interventions that risk direct harm.

Respecting Autonomy and Free, Informed Consent

• IIQ Code (Article 41.1): When obtaining or verifying free and informed consent, the nurse must provide all necessary information, ensure consent remains informed, and respect the client’s right to withdraw or refuse consent at any time.
  OIIQ

• CNA Value (Promoting and Respecting Informed Decision-Making): Prohibits coercion or paternalism. The nurse explores the patient's concerns, explains the risks and benefits objectively, respects their refusal, and collaborates with the team to develop an alternative, comfort-focused plan.
  CNO

• Incidents, Transparency, and Truth-Telling

• OIIQ Code (Article 12): The nurse has a strict legal obligation to promptly disclose any incident or accident resulting from their action or omission, must never attempt to conceal it, and must take immediate steps to mitigate any consequences.
  Gouvernement du Québec

• CNA Value (Being Accountable & Preserving Dignity): Demands honest self-reporting, transparency with the patient and attending team, and using the event to identify systemic unit vulnerabilities rather than hiding an error out of fear of blame.

•  Patient Confidentiality and Professional Boundaries

• OIIQ Code (Articles 34, 38): Upholds strict professional secrecy (secret professionnel) and establishes boundaries regarding personal relationships.
  Gouvernement du Québec

• CNA Value (Maintaining Privacy and Confidentiality): Directs the nurse to redirect family inquiries appropriately, obtain proper consent prior to disclosure, and actively intervene to stop careless hallway or elevator discussions that violate patient privacy.

everyday ethical actions

• Ensuring valid informed consent by verifying patient comprehension before interventions and diagnostic procedures.

• Safeguarding patient privacy and confidentiality

• Challenging, intervening in, or escalating unsafe clinical practices and reporting incidents to prevent patient harm.

• Eliciting, respecting, and advocating for individual patient values, care preferences, and treatment goals, especially when autonomy is vulnerable

• Upholding professional accountability by continuously maintaining competencies, seeking ongoing education, and complying with professional practice standards.

Professional and Legal Obligations

• Mandatory reporting duties: Clear legal obligations exist to act and escalate concerns when vulnerable populations are at risk, including cases of elder abuse or child protection concerns.

• Knowledge of specific regulatory codes: Clinical practice extends beyond broad maxim). For instance, specific regulatory articles govern nurse participation and patient involvement in research studies.

Operationalizing Ethical Practice

• Establishing shared ethical terminology: Cultivating clear communication across interprofessional teams to define and assess moral challenges collectively.

• Clarifying scopes and obligations: Maintaining distinct awareness of employer policies, professional codes of ethics, legal frameworks, and patient expectations.

• Critical self reflection: Examining personal assumptions, implicit biases, and cultural beliefs to prevent them from negatively impacting care delivery.

• Advocating for socially just work settings: Championing healthcare workplaces rooted in social justice where clinicians feel psychologically safe to raise concerns. This aligns with institutional student codes that guarantee fair, supportive learning environments.

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Reframing Leadership within Moral Communities

• Beyond Extroverted Leadership Models

• Moral agency and ethical leadership are not limited to outspoken or extroverted individuals.

• Varied personality traits, including introversion and reflective inquiry, offer distinct strengths in ethical decision-making.

• Collective responsibility: Moral communities decentralize the burden of advocacy, ensuring ethical action is sustained by collective support rather than isolated individual effort.

Moral Agency, Personal Vulnerability, and Professional Limits

• Relational Power and Collective Agency

• Impact does not depend on extroversion or being the most vocal individual; moral influence emerges through collective alignment rather than isolated individual effort.

• Developing ethical strategies begins with recognizing personal limits, core strengths, and implicit biases.

Conscientious Objection and Emotional Boundaries

• Personal circumstances and grief directly impact ethical readiness in clinical situations.

• Transparent communication with colleagues enables ethical self-protection without abandoning patient autonomy or institutional standards.

Nuremberg War Crimes (Doctors' Trial, 1940s):

• Nazi physicians conducted non-consensual medical experiments on concentration camp prisoners, leading to direct legal and ethical prosecution.

Tuskegee Syphilis Study (1932–1972)

he U.S. Public Health Service tracked the natural progression of untreated latent syphilis in approximately 400 Black men in Alabama. Effective penicillin treatment was deliberately withheld after it became the established standard of care, causing horrific disability, death, and familial transmission.

Nutritional Experiments in Canadian Residential Schools (1940s–1950s)

Federal researchers subjected malnourished Indigenous children to deliberate dietary deprivation and controlled interventions to test nutrient requirements and refine Pablum formulas.

U.S. Guatemala Syphilis Experiments (1946–1948)

• Incarcerated individuals, psychiatric patients, and soldiers were intentionally inoculated with venereal diseases without consent to evaluate prophylactic treatments.

Human Radiation Experiments:

• Vulnerable populations, including pregnant women and hospitalized patients, were exposed to plutonium and ionizing radiation without informed consent.

Nuremberg Code (1947):

A foundational 10-point code of research ethics mandating voluntary informed consent, scientifically valid design, prior animal testing, and the complete avoidance of unnecessary physical and mental suffering.

nstitutional Review Boards (IRBs) / Research Ethics Boards (REBs):

• Independent multidisciplinary oversight committees established to review research protocols, enforce consent requirements, and monitor participant safety.

Declaration of Helsinki (1964, World Medical Association)

• International ethical framework governing human biomedical research, prioritizing individual participant health, rights, and well-being above the interests of science or society.

Belmont Report (1979):

• U.S. commission report defining three primary ethical principles for human subject research:

  • Respect for Persons: Acknowledging individual autonomy and protecting individuals with diminished autonomy.

  • Beneficence: Maximizing potential benefits while minimizing potential harms ("do no harm").

  • Justice: Fair, equitable distribution of research burdens and benefits, prohibiting the exploitation of vulnerable groups for the benefit of privileged populations.

Enduring Motivators in History and Bioethics

• Human Motivations Over Time

• Factors that drove historical violations remain present today: scientific pursuit, career advancement, personal convenience, institutional prestige, and financial gain.

• Rejection of moral relativism: Examining past harms through historical context does not excuse them as "products of their time." Instead, it highlights how unchecked ambitions consistently jeopardize the protection of vulnerable groups.

• Environmental custodianship: Contemporary actions regarding ecological preservation and climate policy are frequently compromised by identical pressures: convenience, economic interests, and personal profit.

• Cultural humility: Acting ethically requires ongoing curiosity, acknowledging gaps in personal knowledge, and recognizing that modern practitioners are vulnerable to the same systemic pressures that led to past failures.

ore Distinctions: Law, Morality, and Ethics

Law : formal enforced rules, establish baseline behavioral minimum

evaluated by

MORALITY    Informal cultural/religious frameworks   and Often habitual, socially reinforced norms

ETHICS                     │

   Systematic philosophical reflection      "What ought to be done?"                  nterrogates both legal and moral codes

meta ethic

What is the nature of moral concepts?

Investigates the foundational origins, existence of moral truths, personhood, and cultural relativism.

Does an objective moral duty to preserve life exist across all cultures? What defines a person?

normative ethic

What standards, principles, or virtues ought to guide action?

Develops frameworks, rules, and value systems to determine right versus wrong conduct.

Is deception ever morally permissible in healthcare? Which virtues define a good clinician?

descriptive ethic

How do individuals actually behave and believe?

Empirically observes, documents, and describes real-world practices and perspectives without moral judgment.

How do critical care nurses actually respond when witnessing a breach in clinical practice standards?

applied ethic

How should specific moral dilemmas be resolved in practice?

Employs normative principles to resolve concrete ethical challenges in specialized contexts.

How should a nurse manage systemic workplace intimidation or honor patient autonomy during treatment refusal?

Applied Ethics and Intersecting Domains

The course primarily centers on applied healthcare ethics and bioethics, which intersect with adjacent specialized fields:

• Professional Ethics: Regulatory codes, scopes of practice, and professional accountability.

• Corporate and Business Ethics: Resource allocation, institutional productivity pressures, and healthcare organizational structures.

• Environmental Ethics: Ecological health determinants, planetary health, and their emerging intersections with public health nursing.

descriptive ethic and applied ethic

• Descriptive Ethics is empirical and observational: it records what people actually do or believe in a given setting (e.g., survey data, observed clinician actions during clinical dilemmas).

• Applied Ethics is normative and prescriptive: it analyzes what professionals ought to do when navigating concrete, real-world practice challenges.

Health Ethics and Everyday Nursing Practice

• Distinct Focus of Nursing Ethics

  • Unlike classic bioethics, which often concentrates on novel biotechnologies, resource rationing, or critical end-of-life cases, nursing ethics centers on the everyday moral issues embedded in routine clinical care.

  • Examples include physical or chemical restraint decisions (infringing on patient autonomy), navigating everyday consent, bedside privacy, and balancing safety with personal dignity.

  • Ethical challenges occur continuously in standard practice rather than solely during extraordinary clinical crises.

Historical Roots and Evolution of Nursing Ethics

• Diverse Formative Influences

• Traditional care practices, including Indigenous midwifery and community healing traditions.

• Religious orders and charitable institutions shaping ideals of service, moral character, and purity.

• Gender dynamics and societal perceptions: Florence Nightingale worked to elevate nursing from a historically marginalized, low-status occupation into a respected, disciplined profession, though early frameworks introduced strong hierarchies around gender, race, and submissive virtue.

hisotrical nightale

Professional Role & Autonomy	Framed as an obedient religious or moral "calling"; explicit duty to be an assistant to the physician
Scope of Care	Individualized bedside care centered primarily on purity, personal virtue, and moral uprightness
Confidentiality	Framed through quasi-religious confessional language
Beneficence & Non-Maleficence	Dedicated to avoiding harmful practices
Advocacy & Leadership	Implicit within personal moral rectitude and elevating the standing of the hospital and doctor.

modern nursing pracrtice

Professional Role & Autonomy	Defined as an autonomous profession founded on evidence-based practice, professional self-regulation, and collaborative interprofessional partnerships.
Scope of Care	Holistic health spanning the patient, family, and wider community, addressing social, cultural, and systemic determinants of well-being.
Confidentiality	Formulated as an ethical and legal duty to protect patient privacy, data integrity, and autonomy within a care team.
Beneficence & Non-Maleficence	Preserved as a core priority: advocating for patient safety, promoting health, and actively mitigating pain and suffering.
Advocacy & Leadership	Explicit mandate for systemic advocacy, health equity, cultural safety, and social justice.

Continuing Historical Shift: Marsha Fowler's Scholarship

• Code Scholarship

• The transition in professional identity from physician subservience to independent moral agency is documented by nursing ethics historian Marsha Fowler (key contributor to the development and analysis of the American Nurses Association Code of Ethics).

• Fowler traces nursing's shift away from pure obedience and virtue-based subservience toward an autonomous, socially accountable discipline with distinct ethical duties to patients, society, and the profession itself.

masha fowler shcoarship

• Historiographical Recovery: Marsha Fowler analyzes early 20th-century publications to demonstrate that nursing ethics evolved independently of biomedical ethics rather than as an offshoot.

• Biomedical vs. Nursing Frameworks: While traditional medical ethics historically reinforced patriarchal, physician-led hierarchies, early nursing ethics centered on holistic care, relational duties, and advocacy at the social margins.

Sociocultural Tensions in Nursing History

• Vocation ("Calling") vs. Profession:

• Rooted in Western religious traditions (such as the Sœurs Grises / Gray Nuns in Quebec pioneering public health).

• Early emphasis focused on charity, altruism, and service to marginalized populations.

• The framing of nursing as a self-sacrificing "calling" historically suppressed labor rights, wage negotiations, and safe nurse-to-patient ratios. Modern professionalization reframes nursing as an autonomous choice requiring self-regulation, strategic investment, and equitable working conditions.

Moral Character and Regulation of Private Life:

• Historically, personal integrity and professional conduct were inseparable: moral character dictated suitability for practice.

• Rigid gender and moral policing existed within hospital-based training schools:

  • Marriage historically ended a nurse’s career.

  • Unmarried pregnancy resulted in expulsion on grounds of "immorality," compelling students to conceal pregnancies.

Social Activism vs. Complicity in Systemic Injustice:

• ctivism: Early nurses challenged harmful policies, advocated for marginalized women (including sex workers and patients with STIs), served in World War I, and advanced the women's suffrage movement. In modern healthcare, nurses have driven systemic harm-reduction policies (such as Insite in British Columbia).

• Systemic Failures: The profession participated in institutionalized racism and colonial oppression . Early professional ideals also restricted entry based on racialized and class-based standards of who constituted a "respectable" woman.

Canadian Nursing Trailblazers

• Bernice Redmon: First Black public health nurse in Nova Scotia; barred from Canadian nursing education due to systemic racial segregation, compelling her to complete training in the United States.

• Ruth Bailey and Marjorie Anderson (1948): First Black graduates of a Canadian nursing school (Children's Hospital of Eastern Ontario).

• Maritza Scott (1950): Applied to Saint Joseph’s Hospital in Hamilton, Ontario. Following collective advocacy led by community leaders churches, and allied organizations, she was admitted and graduated with honors of distinction.

egulatory Standards and Global Nursing Values

• OIIQ Conduct Standards

• Emphasizes minimum duties, professional boundaries, non-abandonment, controlled substance accountability, and mandatory continuing professional education.

• Obligation to question unsafe orders: Grounded in public protection (la protection du public), superseding historical hierarchical deference to physicians.

International Council of Nurses (ICN) Core Values

• Unifies global nursing practice around shared human rights, health equity, solidarity, professional advancement, and safe practice settings.

• Universal demand: Despite local staffing strains, high-income healthcare systems remain comparatively resource-rich relative to global health landscapes.

• Technological resilience: The core relational, moral, and embodied nature of nursing ensures its survival through technological and AI-driven shifts.

Clinical (Micro-Level) Focus

• Centers on immediate relational interactions among clinicians, patients, families, and interprofessional teams.

• Core inquiry: "What ought to be done for this specific patient or family right now?"

Organizational (Meso- and Macro-Level) Focus

• Centers on administrative decision-making, resource allocation, institutional culture, and the alignment of mission statements with real-world practices.

• Core inquiry: "What kind of institution are we, and what kind of institution ought we to be?"

• Contemporary Organizational Dilemmas

• Resource allocation: Rationing nursing staff equitably during critical shortages.

• Public vs. private tensions: The ethical implications of private healthcare initiatives pulling labor and resources from public institutions.

• Care for uninsured individuals: Institutional duties toward patients lacking standard health coverage (such as RAMQ).

• Algorithmic governance: Balancing transparency, accountability, and patient autonomy against automated healthcare systems and "black box" algorithms.

• Efficiency vs. holistic care: Administrative targets for throughput and discharge metrics competing directly with therapeutic nursing presence.

Bidirectional Influence: Pandemic CPR Protocols

• The moral distress experienced by frontline nurses required to pause during cardiac arrests for PPE donning prompted institutional bioethics analyses.

• These clinical tensions led hospitals to issue updated, transparent organizational resuscitation guidelines grounded in staff safety and common-good ethics.

• Institutional Frameworks: Accountability for Reasonableness (A4R)

• Developed to guide fair, legitimate priority-setting in resource allocation.

• Emphasizes transparency, publicity, relevant rationales, and appeal mechanisms to ensure healthcare decisions are understandable and defensible to staff and the public.

• Supported by hospital ethics advisors, clinical ethics services, and institutional committees

Structural Transitions: Linking Organizational Ethics to Cultural Safety

• Beyond Individual Competence

• Equity-oriented care, anti-racism, and harm reduction are not simply individual interpersonal choices; they depend directly on institutional support, operational policies, and organizational culture.

• Interpersonal practice and systemic institutional structures meet in the clinical space, setting the stage for Patricia Benner's relational practice models and systemic cultural safety frameworks.

he "In-Between" Space of Nursing Practice

• Everyday Relational Tensions

• Nurses operate continuously in an intermediary position at the bedside:

  • Mediating between the patient's unspoken wishes and differing family expectations.

  • Bridging differing perspectives between physicians (episodic assessments) and the 24/7 bedside nursing team (longitudinal observations).

  • Managing conflicts when capable patients refuse interventions that clinicians believe would offer clinical benefit.

  • Navigating institutional mandates, productivity targets, and resource limits that constrain ethical, compassionate care

sbn application

• Foundational values: Humility, open-mindedness, non-judgmental inquiry, and authentic relational engagement.

• Identifying individual strengths and limitations while leaning on collaborative networks.

• Peer solidarity: Building a trusted professional circle ("find your people") to process moral dilemmas, prevent burnout, and sustain professional integrity over a nursing career

culture humility

• A lifelong, reflective process of self-critique. Clinicians examine their own unexamined assumptions, acknowledge limits in cultural understanding, and confront implicit power imbalances.

culture safety

n outcome defined exclusively by the patient, family, or community receiving care—never determined or self-certified by the healthcare provider or institution.

power dynamic and healthcare advocate

• Clinical encounters involve inherent power asymmetries where providers hold structural and institutional authority.

• Institutional trauma and broken trust: Like a failed "trust fall," experiencing mistreatment, dismissal, or overt harm leads patients to avoid subsequent healthcare interactions, even during acute medical crises.

• Transgender health disparities: Canadian research highlights that transgender individuals frequently encounter hostile, discriminatory, or denying behaviors in acute settings (e.g., emergency departments), directly driving subsequent care avoidance.

instutional accountability

Cultural safety extends beyond individual nurse-patient interactions to demand institutional accountability: modifying organizational protocols, reforming institutional cultures, and addressing systemic biases that perpetuate inequities.

elationality and Indigenous Methodologies (Josie Laveau)

• Ontological Foundation of Relationality

• Relationality defines identity through interconnectedness: individuals are formed and situated through relationships with others, communities, and the land.

• Acknowledged as a specific personal and Métis perspective rather than a monolithic view representing all Indigenous peoples.

• The 6 Rs of Indigenous Research and Practice

  • Grounded in lived experience, community reciprocity, and ethical engagement rather than abstract terminology:

1. Respect: Engaging honorably with individuals, stories, data, and community knowledge.

2. Relevance: Ensuring clinical goals, inquiries, and research directly address the needs and priorities of the community or patient.

3. Responsibility: Upholding accountability for actions, ethical care, and outcomes across relationships.

4. Reciprocity: Fostering mutual, non-extractive exchange where both parties give and receive.

5. Representation: Ensuring community voices, perspectives, and cultural realities are accurately reflected and led by those involved.

6. Relationship: The core pillar; establishing authentic, enduring bonds beyond transactional or clinical boundaries.

realtionality clinical transtion into nrusing practice

• Relevance in care: Framing health and treatment goals in language and concepts that matter to the patient rather than solely through institutional terminology.

• Operationalizing cultural safety and humility: Actively inquiring how patients define health, what relationality means to them, and how family and kinship networks are structured.

• Everyday enactment: Applying these values across clinical bedside interactions, community fieldwork, and shared informal moments (such as sharing a m