W5 Legal Implications in Nursing & Professional Conduct

CNO Standards

  • The following documents outline the accountabilities and responsibilities of nurses concerning refusing assignments and discontinuing nursing services:

    • CNO Code of Conduct (2023)

    • CNO Practice Standard: Discontinuing or Declining to Provide Care (2024)

    • Ask Practice: FAQ: Accountabilities when Discontinuing or Declining to Provide Care

    • CNO Conflict Prevention and Management (2018)

    • CNO Professional Conduct: Professional Misconduct (2019)

CNO Code of Conduct Review

  • Nurses' Ethical Principles:

    • Respects client dignity.

    • Provides inclusive and culturally safe care by practicing cultural humility.

    • Delivers safe and competent care.

    • Works respectfully with the healthcare team.

    • Acts with integrity in the clients’ best interests.

    • Maintains public confidence in the nursing profession.

    • Source: CNO (2024)

Nursing Act 1991: Professional Misconduct

  • Definitions and Regulations:

    • Professional misconduct includes regulations that define the term.

    • Important to note that no explicit definition of professional misconduct includes the term ‘abandonment’.

    • Definitions help guide nurses in understanding what might constitute professional misconduct when refusing assignments or discontinuing services.

    • Source: College of Nurses of Ontario (2017), Practice Guideline: Refusing Assignments and Discontinuing Nursing Services, p. 4

Relevant Definitions of Professional Misconduct in Legislation

  • Health Professions Procedural Code Clauses:

    • Contravening Professional Standards:

    • Contravening a standard of practice or failing to meet it.

    • Informing the Employer:

    • Failing to inform the employer of inability to accept responsibilities in specific areas requiring training or competence.

    • Terms of Professional Service Agreements:

    • Failing to fulfill terms of agreements for professional services.

    • Disgraceful Conduct:

    • Engaging in conduct regarded by members as disgraceful, dishonourable, or unprofessional.

    • Source: College of Nurses of Ontario (2024), Discontinuing or Declining to Provide Care, p. 14

Additional Definitions of Professional Misconduct

  • Discontinuation of Services:

    • It constitutes professional misconduct if professional services are discontinued unless:

    • The client requires discontinuation.

    • Alternative or replacement services are arranged.

    • Client is given a reasonable opportunity to arrange services.

    • Source: College of Nurses of Ontario (2024)

Professional Misconduct vs. Malpractice

Professional Misconduct

  • Definition:

    • An act or omission breaching accepted ethical and professional standards of conduct.

    • Breaches College of Nurses of Ontario standards, ensuring responsible, safe, and adequate client care.

    • Example:

    • Falsifying medical records. Accurate documentation is essential for client safety, reflecting important health and clinical data: failure to document properly jeopardizes client health.

Malpractice/Negligence

  • Definition:

    • Defined by Burkhardt, Nathaniel & Watson (2018) as the failure to provide standard care that is reasonable, implying that care or treatment falling below that standard is negligent.

    • It involves failing to act with due professional care, potentially causing injury, harm, or loss.

    • Example:

    • A nurse neglecting professional development activities may not meet the competency required for safe practice and thus risk providing substandard care.

    • Most provincial regulatory bodies are monitoring continued learning and requiring evidence of competence.

    • References: Burkhardt, Nathaniel & Walton (2018).

Professional Misconduct versus Malpractice (Continued)

Definitions Clarified

  • Professional Misconduct:

    • Failure to comply with rules of conduct set by a governing body the health care provider is admitted to practice under.

  • Malpractice/Negligence:

    • Involves failure to exercise ordinary skill and knowledge, resulting in client damage.

    • Sources: Burkhardt, Nathaniel & Walton (2018), College of Nurses of Ontario (2024)

Malpractice Specifics

  • Nature of Offences:

    • Does not always involve misconduct.

    • Performing lawful acts in a careless manner failing to meet the standards of care.

    • Offenses typically dealt with in civil courts.

Mandatory Reporting

  • Purpose:

    • Mandatory reporting ensures the College of Nurses of Ontario is alerted to concerns that a nurse is practicing unsafely.

    • This allows the College to take action to protect public safety and rehabilitate the nurse if needed concerning:

    1. Professional Misconduct

    2. Sexual Abuse

    3. Incapacity

    4. Incompetence

Failure to Comply with Reporting Obligations

  • Intervention Responsibilities:

    • Nurses must intervene to prevent abusive behavior towards clients by any health care provider and report these incidents to an employer or the College.

    • It is mandatory to report sexual abuse of a client to the College of Nurses of Ontario or risk facing fines up to $25,000 and charges of professional misconduct.

    • Source: College of Nurses of Ontario (2024), Reference Document: Professional Conduct: Professional Misconduct, p. 12

Understanding Obligations

  • Definition of Obligation:

    • An obligation refers to actions a person must take or refrain from to allow others to exercise their rights fully.

  • Nurse Responsibilities:

    • Nurses must comprehend both client rights and their own professional obligations to protect or respect these rights.

    • Source: Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Declining Assignments

  • Nurse Rights:

    • Nurses possess the right to decline assignments or discontinue client care, but must consider implications of abandonment.

    • Situations may arise such as job actions, overtime requests, and unsafe working conditions resulting in conflicts between professional and personal obligations, leading to ethical dilemmas.

    • Source: College of Nurses of Ontario (2024)

Critical Questions

  • Considerations:

    • When would discontinuation of professional services not be deemed misconduct?

    • Should nurses possess the ability to refuse care to clients?

Refusing Assignments Specifics

  • Situational Context:

    • Refusing to work extra shifts does not fall under the definitions of professional misconduct according to the Nursing Act.

  • Notification Responsibility:

    • Nurses must notify employers when unable to accept extra shifts, allowing the employer to seek additional staffing.

  • Care Provision Threat:

    • Leaving clients without care at shift end when no replacement is present poses a serious threat to client safety.

    • This situation does not automatically equate to professional misconduct; context is critical.

    • Source: College of Nurses of Ontario (2024)

Discontinuing Nursing Services

  • Understanding Abandonment:

    • Abandonment occurs when a nurse accepts an assignment and discontinues care without:

    • The client's permission.

    • Arranging suitable alternative or replacement services.

    • Allowing reasonable opportunities for alternatives to be provided.

    • A nurse could be found guilty of professional misconduct under such circumstances.

    • Source: College of Nurses of Ontario (2024), Professional Conduct: Professional Misconduct, p. 5

Guidelines for Decision-Making

  • Resolving Ethical Dilemmas:

    1. Engage in thoughtful consideration of all relevant factors employing an ethical decision-making process.

    2. Foster collaboration through respectful behavior and collegial communication.

    3. Communicate concerns before situations arise, advocating for appropriate staffing.

    • Source: College of Nurses of Ontario (2024)

Conscientious Objection

  • Moral or Religious Grounds:

    • Nurses may encounter situations prompting moral or religious objections to care provision.

    • Responsibilities:

    • Provide emergency care until alternative is available.

    • Failure to provide care constitutes a breach of professional responsibilities and ethical principles, including justice, beneficence, and nonmaleficence.

Accountabilities When Refusing Assignments or Discontinuing Nursing Services

  • Concerns:

    • Nurses may fear that declining work assignments may be construed as abandonment.

    • Situations leading to these considerations include working outside personal competency, excessive workload, or strikes.

Accountability Measures

  • Deciding to Refuse or Discontinue Care:

    1. Assess potential harm to self and patients.

    2. Utilize evidence-based resources for decision-making, considering context.

    3. Communicate concerns with your employer and discuss potential refusal or discontinuation.

    4. Ensure continued patient care, arranging suitable alternatives.

    5. Document decision-making processes and actions taken.

Summary

  • The CNO requires nurses to contemplate all potential options for performing assignments safely before refusal.

  • Clear communication of reasons for refusal to the employer and thorough documentation of steps taken are integral.

  • Prioritization of client safety remains central in all decisions made.