There are many situations that could lead an RN or NP to consider discontinuing or declining to provide client care. These situations could be filled with emotion and a desire to ‘protect one’s license’. Nurses must consider their decisions’ potential impacts on the client and must consider discontinuing or declining to provide care only once all other viable options are explored. It is important to maintain professionalism, effective communication, and safety for all involved.

Professionalism

Professionalism is a foundational principle of nursing practice, encompassing a range of conduct, behaviour, and practice accountabilities that shape a nurse’s interactions within the health care setting. RNs and NPs need to ensure they are always displaying professionalism even in situations where they have a conscientious objection. Conscientious objection refers to a situation when a nurse objects to certain medical procedures or aspects of care, based on the nurse’s religion or conscience. This objection must not be based on fear, prejudice, or convenience. Ideally RNs and NPs have a conversation with their manager prior to a situation occurring in order to minimize risk to the client and establish processes to support safe and efficient care delivery.  Nurses are accountable to:

• Apply their clinical judgement in assessing situations of conflict and collaborate with the client and the employer to determine the most appropriate solutions.
• Carefully navigate potential conflicts arising from differences of opinion, as they cannot stop or decline to provide care solely based on differences of opinion.
• Prioritize continuity of care and seamless transitions ensuring an effective referral when needed, while providing accurate, impartial health information without moral judgment.

Communication

Effective communication facilitates continuity of care by providing essential information to clients, the health care team and employers. When employers know about situations where RNs and NPs are not comfortable with a practice situation, all parties can work together to find a solution in the client’s best interest. Nurses are accountable to:

• Discuss with their employer, health care team and the client any actual or potential occupational health or safety issues, conflicts, or differences of opinion in a timely and effective manner.
• Work to develop and implement strategies to resolve issues that may impact the therapeutic nurse-client relationship or the health care team.
• Inform the client and work with the health care team when discontinuing or declining care.

Safety

Occupational Health and Safety (OHS) Legislation and employer policies are in place to support safe work environments. A safe practice setting supports nursing practice and promotes the delivery of quality care. Nurses are accountable to:

• Provide inclusive and culturally safe care to all clients.
• Participate in fostering an inclusive and culturally safe work environment for health care providers.
• Recognize the limits of their competence and collaborate with the health care team and employer in a timely manner to determine how best to increase the nurse’s competence and meet the client’s needs.
• Advocate for quality practice settings and promote and support strategies for safe client care.
• Refer to OHS legislation and employer policies for direction on resolving work environment concerns.

Maintaining a professional and solutions-based approach, communicating effectively, and taking action to ensure client and health care provider safety are actions all RNs and NPs can take to comply with legislation, regulations, and employer policies. When actions also align with the expectations outlined in the entry-level competencies, practice standards and the code of ethics, RNs and NPs can be confident they are providing safe care and acting in the best interest of clients.

Nursing Advisors for Practice and Education are available to discuss your situation and provide confidential advice and coaching to support you in being accountable for your professional practice. They can be reached by phone at 306.359.4227 or 1.800.667.9945 or by email at practiceadvice@crns.ca.

Resources

• Client Abandonment
• Ending the NP-Client Therapeutic Relationship
• Code of Ethics for registered nurses
• RN Entry-Level Competencies
• RN Practice Standards

RNs require an order or another authorizing mechanism to administer a medication. In this situation a directive, as outlined in the RN Specialty Practices (RNSP) Guideline and as part of an RN Clinical Protocol, could be provided to enable RN administration of flu shots to a client population in a pharmacy.

RN Clinical Protocols are created by the employer – in this case the pharmacist, approved prior to implementation and contain all essential components where:

1. The RNSP is in the interest of the client in their environment. In this case, the pharmacy.
2. There is evidence to support the RNSP. There is ample evidence to support RNs as part of the health care team administering flu shots.
3. A client-specific or client population authorizing mechanism is in place. The clinical protocol required in this example needs to be signed by a physician or NP. Although pharmacists can administer the flu vaccine under their own authority, they are not considered authorized prescribers for RN practice and cannot sign the directive.
4. The required competencies and which RNs will engage in the RNSP are clearly defined. What education and skills are required to engage in the practice or to respond to an untoward outcome?

With an RN Clinical Protocol including a directive is in place and the RN has the competence to safely perform the required activities, RNs can administer flu shots in a pharmacy setting.

Liability Coverage

All RNs, holding a practicing license with the CRNS have liability coverage. RNs interested in supplemental liability coverage for this practice can reach out to the Canadian Nurses Protective Society at 1-800-267-3390 or https://cnps.ca/.

Questions can be directed to the Practice & Education Nursing Advisors at practiveadvice@crns.ca

Resources

• RN Specialty Practices Guidelines 2020

This is an incredibly difficult situation and is one that requires you to intervene. The actions that you are witnessing could be a result of a lack of understanding of the professional obligations of RNs, professional or personal issues impacting the nurses’ ability to respond in an ethical manner in that moment, or they may be racially motivated. No matter what the contributing factors might be, these actions cannot be condoned.

Some of the professional expectations that specifically apply to this situation focus on nurses being accountable for identifying how their personal values, beliefs and positional power comes into play and making a conscious effort to reduce bias and influence. Nurses also must take action to support culturally-safe practice environments and to advocate for health equity for all, particularly the vulnerable and diverse clients and populations that they care for. These expectations of course, intersect with the responsibility for all nurses to conduct themselves professionally and according to the code of ethics, practice standards and entry-level competencies.

As nurses we strive to incorporate knowledge from many sources so we can continually reflect upon and improve our practice. A professional expectation for nurses is that they refuse to be complicit in any behaviors where actions are inhumane or degrading and are expected to intervene and report such behaviors when they are observed or if reasonable grounds exist to suspect their occurrence.  One of the ways nurses can do this is to develop strong conflict management skills, an ability to de-escalate volatile situations, to have a full awareness of agency policy in managing instances of workplace violence and to uphold organizational commitments that might focus on respectful environments and being courageous. One or more of these could become a learning goal in your mandatory CCP learning plan and should you find certain resources helpful, you could share those within the CRNS Facebook group to assist others with their journey.

All professional obligations matter and make the difference between ethical care and unethical treatment that can have lasting effects on all those involved in the situation. Addressing situations of workplace violence, although generally difficult, actively improves patient experience and impacts patient, health care professional and employee workplace safety. It may even prevent tragic and preventable losses of life such as Joyce Echaquan. Would the outcome have been different for her and her family and the nurses involved if someone had intervened?

One tool that can be utilized in responding is the CPR Racism card. It was specifically developed by Dr. Holly Graham with the intent of it enabling nurses and others to take action when they witness racist behaviors in health care settings. To learn more about the tool, click here.

For more information about responding to workplace violence, please see other CRNS articles within this series. They can be found here.  You can also review these resources on preventing violence in the workplace or register for a course on recognizing the risk of violence in the workplace and taking action if it occurs. You might also want to check out the resources available on the Saskatchewan Union of Nurses website.

CRNS Practice & Education nursing advisors are available to discuss scenarios similar to this one and other professional practice situations with you. They can be reached at practiceadvice@crns.ca.

If you witness harassment or workplace violence of any kind, you are expected to take action to stop the violence. In demonstrating professional behaviour, RNs are expected to intervene, and report when others fail to respect the dignity of a person they are caring for or a colleague (including students). It is important to recognize that to be silent and passive is to condone the behaviour. RNs must speak up, facilitate conversation, and adjudicate disputes as appropriate or as required. RNs work toward preventing and minimizing all forms of violence by anticipating and assessing the risk of violent situations and by collaborating with others to establish preventive measures.

All RNs regardless of the type of practice or practice setting, need to comply with the  CNA Code of Ethics, 2017, RN Practice Standards, RN Entry-Level Competencies, The Registered Nurses Act, 1988, CRNS Bylaws 2024, employer policies and other legislation, as relevant. This applies to witnessing bullying or harassment in the workplace.

If you have observed harassment in your workplace, here are ways you can take action:

• Check in with the person who has experienced the violence. Acknowledge what has happened and empathetically assist them to access supports as needed.
• Keep a written account of events including the following information:
  • The date, time and what happened in as much detail as possible.
  • The names of witnesses.
  • The outcome of the event.
• Report the incident to your employer to try to resolve the issue internally. Refer to the organization's harassment policy for information on reporting options and investigation process (Retrieved from saskatchewan.ca, March 4, 2024).

These are a few examples of how you can address workplace violence when you see it happen. Acting and addressing the behaviour is critical to stopping it from occurring again and fostering a healthy workplace environment and team. Supporting the idea of reporting these situations, the Saskatchewan Association for Safe Workers in Health has launched the Campaign for Change of #IWillReport. For more information, you can watch the video here https://youtu.be/Ji_bEXUZ3SA.

The CRNS Nursing Advisors are available to assist you as you work through situations like this and others. They can be reached by email at practiceadvice@crns.ca or by calling the toll-free number at 1-800-667-9945.

Resources

Government of Saskatchewan: Bullying and Harassment in the Workplace

Workplace violence is a term that represents actions such as harassment, bullying and the attempted, threatened or actual conduct of a person that causes or is likely to cause harm to the psychological or physical safety of others.

The general approach of the CRNS is to work with members on identifying and understanding the situation being focused on, to outline the professional responsibilities and accountabilities of RNs or NPs in that situation, to offer guidance and support on how to resolve professional practice issues such as this at the lowest level, and to support the development or refinement of competencies throughout the process. Advisors can assist by identifying key resources or processes that might be beneficial. There is generally an emotional toll when nurses are involved in situations when workplace violence occurs. It is important to recognize this and to take action on ways to care for yourself to ensure you maintain your fitness to practice in a safe and competent manner.

There are several applicable nursing practice resources, such as the foundational documents of the RN or NP practice standards (PS) and entry-level competencies (ELCs), as well as the Canadian Nurses Association (CNA) Code of Ethics (COE). These documents contain many statements that speak to the professional accountabilities in relation to workplace violence. For example, an entry-level competency is RNs participate in creating and working to maintain healthy workplaces. Further expectations identified in practice standards are RNs are accountable for their actions and behave professionally. Ethically, RNs are expected to treat each other respectfully and refrain from any form of workplace bullying.

Further, as of May 17, 2024, The Saskatchewan Employment Act will require that all workplaces in Saskatchewan implement a policy statement and prevention plan (PSPP) to eliminate workplace violence. As such, the CRNS is launching a series of articles that may be helpful when understanding professional obligations, legislative requirements and practical advice on addressing workplace violence.

Some of the scenarios in the series will highlight when a nurse:

• feels targeted and harassed by others in the workplace;
• witnesses workplace violence towards others such as a colleague, student or other health professional;
• witnesses bullying or harassment directed towards a client, patient or resident in the workplace;
• is accused of perpetrating workplace violence against others, or questions the nature of their own behaviors or actions; or
• is part of a healthcare workplace group connected online or through group texts where overt or covert incidents of cyberbullying occur.

Violence in the workplace is a very challenging issue that can take many forms. We hope that this series will deepen your understanding of the issue and your commitment to ending workplace violence.

Here are a few suggestions for how to resolve the first issue in our series, where the RN is the target of workplace violence. First, keep detailed factual records. Firmly tell the person that their behaviour is not acceptable and ask them to stop. You can ask a person you trust, such as supervisor or union member to be with you when you approach the person (Retrieved from ccohs.ca, March 4, 2024).  If you are unsuccessful in resolving it yourself after a frank and respectful discussion, the next action is generally to report the person’s actions to your manager. Focus on the facts as much as possible and ask for their involvement and collaboration in seeking resolution. Bring a solutions-based approach and be open to suggestions. You are showing leadership by seeking to resolve this.

All RNs, including both of you, are expected to comply with the professional obligations outlined in the practice standards, entry-level competencies and code of ethics. Reviewing these documents will help you to understand, take action on and speak clearly about these obligations as you seek to resolve the issue.

In Saskatchewan, The Employment Act outlines the employer obligation to provide a workplace that is free from harassment or abuse. Most facilities have code of conduct policies that outline expectations. You have a right and a responsibility to contribute to a workplace that is healthy, respectful and psychologically safe. This responsibility also lies with your colleagues and manager. If collaboration with the employer does not bring about a satisfactory resolution, you could utilize the framework outlined in the Resolving Professional Practice Issues: Toolkit for Registered Nurses (2019) to continue to escalate your concerns in a respectful and professional manner as you work towards resolution. The CRNS Nursing Advisors are also available to assist you and can be reached by email at practiceadvice@crns.ca or by calling the toll-free number at 1-800-667-9945. If you work in a unionized environment, union representatives can support and assist you as well.

One of the tools that CRNS can offer to both RN and non-RN managers is the Toolkit for Managers of RNs. Contained within the toolkit are a number of resources that highlight the professional accountabilities and responsibilities of RNs related to scope of practice, professional practice or clinical practice. A new resource focused on workplace violence is being added soon. You can share this information and encourage access of these resources.

Please watch for more articles in this series on workplace violence where we will highlight other aspects of this complex topic.

Varying forms of digital communication have become increasingly utilized in both our personal and professional lives. This includes the use of smartphones, iPads, tablets, etc. While the first consideration that comes to mind may be around privacy, several other points exist.

Privacy

Legislation and employer policies hold RNs and NPs responsible for maintaining and safeguarding patients' information. You must consider the risk of having your phone stolen, lost, or accessed by someone outside the circle of care. Factors such as the wi-fi connection and network security also play a part and can add to the risk of privacy breaches. Entry-Level Competency 2.4 mandates that RNs and NPs adhere to regulations, practice norms, ethical guidelines, and organizational protocols to safeguard client privacy, confidentiality, and security. Standard 3, Indicator 30 of the RN Practice Standards underscores the importance of maintaining professional boundaries, privacy, and confidentiality with clients. Additionally, the Code of Ethics emphasizes privacy protection across various domains, including in Section E. #7, which highlights RNs and NPs' adherence to policies aimed at preserving the privacy of individuals receiving care, including measures within information technology systems.

Professional Boundaries and Expectations

Aside from privacy issues, expectations and boundaries between the RN or NP and the family or colleague they are texting must be considered. If using your own cell phone to text, are patients accessing you outside work hours? When is it appropriate to respond? What are the expectations and assumptions when utilizing text messaging as a form of communication? Are there clear guidelines put in place to preserve and protect the professional relationship?

Employer Policies and Best Practices

Employer policies must also be referenced and followed. RNs and NPs must ensure they follow procedures and utilize best practices for communication and infection control. For example, does the employer have its own smartphone on a secured network with specific safeguards and instructions on when and how to erase the data or ensure it is properly stored? Are there policies around how to ensure proper cleaning of cell phone devices? We must consider employer direction and expectations for what is acceptable within each setting and follow best practice guidelines.

Documentation Standards

Finally, consider that texts surrounding patient care should be captured in the patient's medical record. RNs and NPs may face challenges complying with professional and legal obligations for documentation when providing care through text. How are you documenting text conversations or photos? What is the policy around how to safely and securely do it, or is it acceptable at all?

Key Points to Take Forward

• Each employer and practice setting will have a specific direction and policy for using personal smartphones. It is important to know what these are and always practice within the Code of Ethics, Entry-Level Competencies, and Practice Standards.
• Consider utilizing an employer-provided device and always use a secured network with safeguards in place, such as an app that encrypts data being sent.
• Proper processes should be in place, such as how to clean them, how to transfer data to the client’s medical record, when to delete texts, and password/access updates.
• Reducing the risk of privacy breaches is important. Always take precautions, such as not using personal identifiers when sending messages. Make sure you are utilizing strong passwords and finger scans or face scans and all other available safeguards to protect the privacy and confidentiality of the patient.

Practice Advisors are available to discuss your situation and provide confidential advice and coaching to support you in being accountable for your professional practice. They can be reached by phone at 306.359.4227 or 1.800.667.9945 or by email at practiceadvice@crns.ca.

Resources:

Mobile Devices in the Workplace – InfoLAW Article

Ask a Lawyer: Texting updates to other health professionals

Legal case study: Distraction by cell phone

Documentation Guideline CRNS, 2021

Registered Nurse Entry-Level Competencies

Code of Ethics

Practice Standards

References:

Canadian Nurses Protective Society (2023). InfoLaw: Mobile Devices in the Workplace. Accessed at https://cnps.ca/article/mobile-devices-in-the-workplace/

Canadian Nurse Association. (2017). Code of ethics for registered nurses. Retrieved from: https://www.crns.ca/wp-content/uploads/2018/11/Code-of-Ethics-2017-Edition.pdf

College of Registered Nurses of Saskatchewan (2019). RN Entry-Level Competencies. Retrieved from: https://www.crns.ca/wp-content/uploads/2019/09/RN-Entry-Level-Competencies-2019.pdf

College of Registered Nurses of Saskatchewan (2019). Registered Nurse Practice Standards. Retrieved from: https://www.crns.ca/wp-content/uploads/2019/09/RN-Practice-Standards-2019.pdf