128 Professional Standards

ACCO U NTA B I L ITY

K N OW L E D G E

CO M PE T E N C E

E T H I CS

SE RV I C E

SE L F- R EG U L AT I O N

FOR REGISTERED NURSES

AND NURSE PRACTITIONERS

Professional Standards

1 “Nurse” refers to the following CRNBC registrants: registered nurses,nurse practitioners, licensed graduate nurses, student nurses.

ABOUT THIS DOCUMENTThis document has been sectioned into four parts tomake it easier for you to find the information you needto support your practice as a nurse.1

The Introduction explains the purpose of theProfessional Standards and how they can help you inyour practice.

Part two includes the six Professional Standards withindicators illustrating how each is applied in four mainareas of practice.

The third part is a section from the Canadian NursesAssociation Code of Ethics for Registered Nurses. Itidentifies and defines eight nursing values and theresponsibilities associated with each.

The fourth part of the document includes five helpfulappendices.

WHERE TO GET ASSISTANCEFor further information on the Professional Standardsor any nursing practice issue, contact CRNBC PracticeSupport at 604.736.7331 (ext. 332) or toll-free inCanada 1.800.565.6505. E-mail [email protected]

CRNBC STANDARDS OF PRACTICE

CRNBC is responsible under the HealthProfessions Act for setting standards of practicefor its registrants. CRNBC Standards include: • professional standards;• practice standards; and• scope of practice standards.

Professional StandardsProfessional Standards are statements aboutlevels of performance that nurses are requiredto achieve in their practice. They provide anoverall framework for the practice of nursing inBritish Columbia.

Practice StandardsPractice Standards set out requirements relatedto specific aspects of nurses’ practice.

Scope of Practice StandardsScope of Practice Standards set out standards,limits and conditions related to the scope ofpractice for registered nurses and nursepractitioners.

All CRNBC Standards are available online atwww.crnbc.ca

CRNBC's mandate is to ensure that all individuals seeking entry to practice

and maintaining registration are competent and ethical professionals. The

College does this by setting standards, supporting registered nurses to meet

standards and acting if standards are not met.

CRNBC’sMandate

Professional StandardsFOR REGISTERED NURSES AND NURSE PRACTITIONERS

2 College of Registered Nurses of British Columbia

mailto:[email protected]

http://www.crnbc.ca

Appendix 1 - Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . 26

Appendix 2 - Applying Professional Standards in Practice . . . . 27

Appendix 3 - CRNBC Resources . . . . . . . . . . . . . . . . . . . . . . . . . 29

Appendix 4 - Guidelines for ResolvingProfessional Practice Problems . . . . . . . . . . . . . . 32

Appendix 5 - Guidelines for Taking Action on Nurses’ Unacceptable Behaviour . . . . . . . . . . 35

Canadian Nurses Association Code of Ethics for Registered Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Standard 1: Responsibility and Accountability . . . . . . . . . . . . . . . . . . . 6

Standard 2: Specialized Body of Knowledge . . . . . . . . . . . . . . . . . . . . 8

Standard 3: Competent Application of Knowledge . . . . . . . . . . . . . . 10

Standard 4: Code of Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Standard 5: Provision of Service in the Public Interest . . . . . . . . . . . 14

Standard 6: Self-regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CONTENTS

© College of Registered Nurses of British Columbia/July 2010 Pub. No. 128


College of Registered Nurses of British Columbia 3

Standards and Indicators

Appendices

WHAT ARE THE PROFESSIONAL STANDARDS FOR NURSES?

A standard is a desired and achievable level ofperformance against which actual performance can becompared. It provides a benchmark below whichperformance is unacceptable.

The Professional Standards are statements about levelsof performance that nurses are required to achieve intheir practice. They reflect the values of the nursingprofession and clarify what the profession expects ofnurses. They represent the criteria against whichnurses’ practice in British Columbia is measured by thepublic, clients, employers, colleagues and themselves.

IndicatorsIndicators illustrate how each Professional Standard isapplied and met in each area of practice – clinical,education, administration and research. Indicatorsprovide specific criteria that are used, when applicable,to measure the actual performance of an individualnurse. The indicators in this document are not writtenin order of importance, nor are they intended to be anexhaustive list of criteria for each ProfessionalStandard.

Regardless of their primary area of responsibility,nurses may assume responsibilities in other practiceareas. For example, a nurse whose primaryresponsibility is for clinical practice may at timesassume responsibilities for education (teaching astudent in practicum), administration (acting manageror supervisor) and/or research (collecting data for aresearch or quality improvement study). The samediversity in practice may be experienced by nurseswhose primary responsibility is for education,administration or research. Nurses in thesecircumstances will find direction for their practice byreferring to indicators related to these other practiceareas.

WHY HAVE PROFESSIONAL STANDARDS?

The primary purpose of the Professional Standards is toguide and direct nurses’ practice. Through theProfessional Standards, CRNBC meets its legalresponsibility to regulate nurses’ practice in the publicinterest and address incompetent, impaired orunethical practice among nurses.

Nursing has a proud history of service to the public, and the public expects

competent nurses to provide safe and ethical nursing care. In British

Columbia, the public has entrusted the College of Registered Nurses of British

Columbia (CRNBC), through the Health Professions Act, with the

responsibility for establishing, monitoring and enforcing standards of practice

and professional ethics for registered nurses and nurse practitioners.



Introduction

In addition to using the Professional Standards toprotect the public through regulation of nurses’practice, they are used by CRNBC in the process forreviewing and recognizing entry-level and re-entryeducation programs for registered nurses and nursepractitioners in British Columbia.2 The ProfessionalStandards are also used to: develop administrativeguidelines; explain expectations of nurses’ practice tothe public and other health care professionals; and toprovide a legal reference for reasonable and prudentpractice.

The Professional Standards can be used by nurses tosupport their individual practice (e.g., as a tool for self-assessment). They can also be used to assist agenciesto develop systems that support nurses to meet CRNBCStandards (e.g., orientation programs). For moreinformation, see Appendix 2: Applying ProfessionalStandards in Practice.

WHO HAS RESPONSIBILITY FOR THE PROFESSIONAL STANDARDS?

It is the responsibility of individual nurses to actprofessionally and be accountable for their ownpractice. All nurses are responsible for understandingthe Professional Standards and applying them to theirpractice, regardless of their setting, role or area ofpractice. The policies of employers or otherorganizations cannot relieve individual nurses ofaccountability for their own actions or their primaryobligation to meet these Professional Standards.

CRNBC is responsible for assuring that the profession asa whole carries out its commitment to the public. This isachieved in part through establishing and regularlyreviewing the Professional Standards, and providingresources to support nurses in understanding andapplying them. Employers have an obligation to provideessential support systems, including human andmaterial resources, so that nurses are able to meet theseProfessional Standards.

2 New graduates are expected to meet CRNBC’s Professional Standards in their beginning practice. The CRNBC document, Competencies in the Context of Entry-level Registered Nurse Practice in British Columbia, gives further details of the expectations for entry-level practice.



http://www.crnbc.ca/WhatNursesDo/TypesOfNurses/Pages/RegisteredNurse.aspx


RESPONSIBILITY AND ACCOUNTABILITY:Maintains standards of nursing practice and professional conduct determined by CRNBC

and the practice setting.

CLINICAL PRACTICE

1. Is accountable and takes responsibility for ownnursing actions and professional conduct.3

2. Functions within the legally recognized scope ofpractice4 and within all relevant legislation.5

3. Follows and/or helps to develop agency ordepartment policies and evidence-based carestandards.

4. Takes action6 to promote the provision of safe,appropriate and ethical care to clients.7

3 Professional conduct includes demonstrating honesty, integrity and respect. See the glossary for a definition of “professional conduct.”

4 The scope of practice for nurses is set out in the Nurses (Registered) and Nurse Practitioners Regulation under the Health Professions Act and is complementedby standards, limits and conditions established by CRNBC.

5 Relevant legislation is legislation that affects the practice of nursing by: a) setting out the scope of practice of another profession (e.g., regulations under theHealth Professions Act); b) requiring adherence to certain conditions (e.g., Freedom of Information and Protection of Privacy Act); or c) directing the behaviour ofcitizens of the province or country (e.g., the Criminal Code of Canada). For a summary of legislation affecting nursing practice, refer to the CRNBC document,Legislation Relevant to Nurse's Practice.

6 Taking action includes advocacy.

7 See the glossary for a definition of the term “client.”

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I N D I C A T O R S

EDUCATION


2. Functions within the legally recognized scopeof practice4 and within all relevant legislation.5

3. Follows and/or develops agency, departmentor education policies and evidence-based carestandards.

4. Takes action6 to promote the provision of safe,appropriate and ethical care.

I N D I C A T O R S



http://www.crnbc.ca/downloads/328.pdf

http://www.crnbc.ca/CRNBC/RegulationOfNurses/Pages/Default.aspx

http://www.crnbc.ca/CRNBC/RegulationOfNurses/Pages/Default.aspx

I N D I C A T O R SI N D I C A T O R S

ADMINISTRATION



3. Follows, develops and/or changes organizationpolicies and evidence-based care standards.


RESEARCH



3. Follows and/or develops agency or departmentpolicies and evidence-based care standards.


Refer to Appendix 3: CRNBC Resources on page 29 for information about resources and services to support your practice.



1



SPECIALIZED BODY OF KNOWLEDGE:Bases practice on the best evidence from nursing science and other sciences and

humanities.

CLINICAL PRACTICE

1. Knows how and where to find neededinformation to support the provision of safe,appropriate and ethical client care.

2. Shares nursing knowledge with clients,colleagues, students and others.

3. Interprets and uses current evidence fromresearch and other credible sources to makepractice decisions.

4. Understands and communicates nursing’scontribution to the health of clients.

5. Uses relationship and communication theoryappropriately in interactions with clients,colleagues and others.

2

I N D I C A T O R S

EDUCATION

1. Knows how and where to find neededinformation to support the delivery of safe,appropriate and ethical nursing and healtheducation.


3. Interprets and uses current evidence fromresearch and other credible sources to makeeducation decisions.


5. Uses relevant learning and communicationtheory to create a professional learningenvironment.

I N D I C A T O R S




ADMINISTRATION

1. Knows how and where to find neededinformation to support the provision of safe,appropriate and ethical nursing practice andclient care.


3. Interprets and uses current evidence fromresearch and other credible sources to makeadministrative decisions.

4. Understands and communicates nursing’scontribution to the health of clients and thedelivery of nursing services.

5. Uses knowledge of organizational behaviourand communication theory to create anenvironment in which cooperation,professional growth, and mutual respect canflourish.

RESEARCH

1. Knows how and where to find neededinformation to support knowledge developmentfor evidence-based, safe, appropriate andethical nursing practice and client care.

2. Shares nursing knowledge with clients,colleagues, students, the scientific communityand others.

3. Interprets and uses current evidence fromresearch and other credible sources to planand conduct research.


5. Uses knowledge of communication theory toshare the practice implications and policyrelevance of research in a meaningful way withnurses and others.


2

8 Whenever possible, nurses involve clients in assessment, decision-making about client status, care planning, implementation and evaluation.

9 The timeliness of documentation will be dependent upon the setting. Settings in which the client acuity, complexity and variability is high will require more frequentdocumentation than settings in which clients are less acute, less complex and/or less variable.



COMPETENT APPLICATION OF KNOWLEDGE:Makes decisions about actual or potential problems and strengths, plans and performs

interventions, and evaluates outcomes.

CLINICAL PRACTICE

1. Collects information on client status from avariety of sources8 using assessment skillsincluding observation, communication andphysical assessment.

2. Identifies, analyzes and uses relevant and validinformation when making decisions about clientstatus and reporting client outcomes.

3. Communicates client status, using verifiableinformation, in terminology used in the practicesetting.

4. Develops plans of care that include data aboutassessments, decisions about client status,planned interventions and evaluation criteria forclient outcomes.

5. Sets priorities when planning and giving care.

6. Carries out interventions in accordance withpolicies, guidelines and care standards.

7. Evaluates client’s response to interventions andrevises the plan as necessary.

8. Documents timely9 and appropriate reports ofassessments, decisions about client status,plans, interventions and client outcomes.

9. Initiates, maintains and terminates professionalrelationships in an appropriate manner.

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I N D I C A T O R S

EDUCATION

1. Collects information on individual and grouplearning needs from a variety of sources usingassessment skills including observation andcommunication.

2. Identifies, analyzes and uses relevant and validinformation when planning education.

3. Communicates learning needs of individuals andgroups using verifiable information.

4. Plans education that addresses learning needsand strengths and includes evaluation criteria.

5. Sets priorities when planning and providingeducation.

6. Teaches using appropriate instructional methodsand relevant learning theory.

7. Evaluates attainment of learning objectivesusing valid and reliable measures and revisesstrategies as necessary.

8. Establishes and maintains appropriateeducation records.


I N D I C A T O R S




ADMINISTRATION

1. Collects information about organizational statusfrom a variety of sources using assessment skillsincluding observation and communication.

2. Identifies, analyzes and uses relevant and validinformation when determining organizationalproblems or status.

3. Communicates organizational problems andstatus using verifiable information.

4. Plans administrative and other strategies toaddress organizational problems and strengthswith accompanying evaluation criteria.

5. Sets priorities when planning and implementingadministrative and other strategies.

6. Implements administrative and other identifiedstrategies.

7. Evaluates process and/or outcomes of strategiesand revises as necessary.

8. Establishes and maintains appropriate systems tomanage clinical and administrative information.


RESEARCH

1. Collects research information from a variety ofsources using valid and reliable data collectioninstruments and methods.

2. Identifies, analyzes and uses relevant and validinformation in nursing research projects.

3. Develops and communicates research questionsor hypotheses that are relevant andresearchable.

4. Writes research proposals to address statedquestions/hypotheses.

5. Sets priorities when planning and conductingresearch.

6. Conducts research in accordance with acceptedresearch methods and procedures and/orsupervises research assistants.

7. Analyzes and interprets qualitative andquantitative data.

8. Writes appropriate reports and articles forpublication.



3

10 Part 3 of this document contains the nursing values and responsibility statements from the CNA Code of Ethics for Registered Nurses. The full document isavailable on the CNA website www.cna-aiic.ca



CODE OF ETHICS:Adheres to the ethical standards of the nursing profession.

CLINICAL PRACTICE

1. Upholds the values contained in the CanadianNurses Association (CNA) Code of Ethics forRegistered Nurses,10 namely:- Providing safe, compassionate, competent

and ethical care- Promoting health and well-being- Promoting and respecting informed

decision-making- Preserving dignity- Maintaining privacy and confidentiality- Promoting justice- Being accountable

2. Consistently practises according to the ethicalresponsibilities in the CNA Code of Ethics forRegistered Nurses.

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EDUCATION

1. Upholds and supports others to uphold thevalues contained in the Canadian NursesAssociation (CNA) Code of Ethics for RegisteredNurses,10 namely:- Providing safe, compassionate, competent



2. Consistently practises and supports others topractise according to the ethicalresponsibilities in the CNA Code of Ethics forRegistered Nurses.

I N D I C A T O R S

http://www.cna-aiic.ca




ADMINISTRATION





RESEARCH






4

11 Team members may be from more than one practice setting.

12 Nurses are frequently involved in assignment. Delegation, on the other hand, is a legal term used to describe the transfer of authority from one individual toanother and entails distinct responsibilities and accountabilities for all parties involved. For advice regarding delegation from and to other members of the healthcare team, contact a CRNBC nursing practice consultant or advisor.

13 Improving client care includes creating and maintaining practice environments that support safe and ethical care.

14 The Health Professions Act requires nurses to report situations in which a health professional’s fitness to practise, competence to practise or sexual misconductmay pose a significant risk to the public. More information is available in the CRNBC Practice Standard Duty to Report.



PROVISION OF SERVICE IN THE PUBLIC INTEREST:Provides nursing services and collaborates with other members of the health care team in

providing health care services.

CLINICAL PRACTICE

1. Communicates, collaborates and consults withnurses and other members of the health careteam11 about the client’s care.

2. Assigns12 and delegates appropriately to othermembers of the health care team.

3. Guides other members of the health care teamas appropriate.

4. Advocates and participates in changes toimprove client care13 and nursing practice.

5. Reports unsafe practice or professionalmisconduct to appropriate person or body.14

6. Assists clients to learn about the health caresystem and accessing appropriate health careservices.

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I N D I C A T O R S

EDUCATION

1. Communicates, collaborates and consults withnurses and others about education.

2. Advocates and provides education for nursesand others regarding assignment12 anddelegation.

3. Guides and supervises educational staff andstudents as appropriate.

4. Advocates and takes action to implementchanges that improve client care13 andeducational practice.

5. Reports unsafe practice or professionalmisconduct to appropriate person or body.14

6. Assists colleagues, students and others tolearn about nursing practice and health careservices.

I N D I C A T O R S

http://www.crnbc.ca/Standards/DutyToReport/Pages/Default.aspx




ADMINISTRATION

1. Communicates, collaborates and consults withnurses and other members of the health careteam11 about the provision of health care services.

2. Advocates and develops policies that clearlyoutline the responsibility and accountability for allinvolved in assignment12 and delegation.

3. Guides and supervises staff and others involvedin the planning and delivery of health careservices as appropriate.

4. Advocates, directs and participates in changesto improve client care13 and administrativepractice.

5. Takes appropriate action or reports unsafepractice or professional misconduct toappropriate person or body.14

6. Assists clients, colleagues, students and othersto learn about nursing practice and health careservices.

RESEARCH

1. Communicates, collaborates and consults withnurses and other researchers about research.

2. Interprets research evidence to guide policydevelopment regarding assignment12 and delegation.

3. Guides and supervises members of theresearch team as appropriate.

4. Advocates and participates in changes thatpromote evidence-based client care13 andimproved conduct of research.

5. Reports unsafe practice or professional mis-conduct to appropriate person or body.14

6. Assists colleagues, students and others to learn about the health care system and theinfluence of research on nursing practice andhealth care services.


5



15 Includes a combination of practice hours and personal practice review requirements.

SELF-REGULATION:Assumes primary responsibility for maintaining competence and fitness to practise.

CLINICAL PRACTICE

1. Maintains current registration.

2. Practises within own level of competence.

3. Meets the requirements for continuingcompetence,15 including investing own time,effort or other resources to meet identifiedlearning goals.

4. Maintains own physical, psychological andemotional fitness to practice.

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EDUCATION





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ADMINISTRATION





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The Code of Ethics for Registered Nurses gives guidance fordecision-making concerning ethical matters, serves as ameans for self-assessment and reflection regarding ethicalnursing practice and provides a basis for peer-reviewinitiatives. The Code not only educates nurses about theirethical responsibilities, it also informs other health careprofessionals and members of the public about the moralcommitments expected of nurses. It applies to nurses in allpractice settings whatever their position or responsibility.CRNBC’s Board has adopted Part 1 of the Canadian NursesAssociation (CNA) Code of Ethics for Registered Nurses.

Standard 4: Code of Ethics requires nurses to uphold thevalues of, and practise in accordance with the ethicalresponsibilities in the CNA Code of Ethics for RegisteredNurses. This section is taken from the CNA Code. Thecomplete Code of Ethics for Registered Nurses document isavailable on the CNA website www.cna-aiic.ca Words orphrases in bold print in this section are found in theglossary included in the CNA Code of Ethics for RegisteredNurses.

Reprinted with permission of the Canadian Nurses Association

Nurses in all domains of practice bear the ethicalresponsibilities identified under each of the seven primary nursing values.1 These responsibilities apply tonurses’ interactions with individuals, families, groups,populations, communities and society as well as withstudents, colleagues and other health-care professionals.

The responsibilities are intended to help nurses applythe code. They also serve to articulate nursing values toemployers, other health-care professionals and the pub-lic. Nurses help their colleagues implement the code,and they ensure that student nurses are acquaintedwith the code.

1 The value and responsibility statements in the code are numbered and lettered for ease of use, not to indicate prioritization. The values are related andoverlapping.

Canadian Nurses AssociationCode of Ethics for Registered Nurses

Part I: Nursing Values and Ethical Responsibilities

http://www.cna-aiic.ca



ETHICAL RESPONSIBIL IT IES:

1. Nurses have a responsibility to conduct themselvesaccording to the ethical responsibilities outlined inthis document and in practice standards in whatthey do and how they interact with persons receivingcare as well as with families, communities, groups,populations and other members of the health-careteam.

2. Nurses engage in compassionate care through theirspeech and body language and through their effortsto understand and care about others’ health-careneeds.

3. Nurses build trustworthy relationships as thefoundation of meaningful communication,recognizing that building these relationshipsinvolves a conscious effort. Such relationships arecritical to understanding people’s needs andconcerns.

4. Nurses question and intervene to address unsafe,non-compassionate, unethical or incompetentpractice or conditions that interfere with their abilityto provide safe, compassionate, competent andethical care to those to whom they are providingcare, and they support those who do the same.

5. Nurses admit mistakes2 and take all necessaryactions to prevent or minimize harm arising from anadverse event. They work with others to reduce thepotential for future risks and preventable harms.

6. When resources are not available to provide idealcare, nurses collaborate with others to adjustpriorities and minimize harm. Nurses keep personsreceiving care, families and their employersinformed about potential and actual changes todelivery of care. They inform employers aboutpotential threats to safety.

7. Nurses planning to take job action or practising inenvironments where job action occurs take steps tosafeguard the health and safety of people during thecourse of the job action.

8. During a natural or human-made disaster, includinga communicable disease outbreak, nurses have aduty to provide care using appropriate safetyprecautions.

9. Nurses support, use and engage in research andother activities that promote safe, competent,compassionate and ethical care, and they useguidelines for ethical research3 that are in keepingwith nursing values.

10. Nurses work to prevent and minimize all forms ofviolence by anticipating and assessing the risk ofviolent situations and by collaborating with others toestablish preventive measures. When violencecannot be anticipated or prevented, nurses takeaction to minimize risk to protect others andthemselves.

2 Provincial and territorial legislation and nursing practice standards may include further direction regarding requirements for disclosure and reporting.

3 See Ethical Research Guidelines for Registered Nurses (CNA, 2002) and the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans(Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, & Social Sciences and Humanities Research Council, 1998).

A . PROVIDING SAFE, COMPASSIONATE, COMPETENT AND ETHICAL CARENurses provide safe, compassionate, competent and ethical care.




1. Nurses provide care directed first and foremosttoward the health and well-being of the person,family or community in their care.

2. When a community health intervention interfereswith the individual rights of persons receiving care,nurses use and advocate for the use of the leastrestrictive measures possible for those in their care.

3. Nurses collaborate with other health-care providersand other interested parties to maximize healthbenefits to persons receiving care and those withhealth-care needs, recognizing and respecting theknowledge, skills and perspectives of all.

B. PROMOTING HEALTH AND WELL-BEINGNurses work with people to enable them to attain their highest possible level of health and well-being.


1. Nurses, to the extent possible, provide persons intheir care with the information they need to makeinformed decisions related to their health and well-being. They also work to ensure that healthinformation is given to individuals, families, groups,populations and communities in their care in anopen, accurate and transparent manner.

2. Nurses respect the wishes of capable persons todecline to receive information about their healthcondition.

3. Nurses recognize that capable persons may place adifferent weight on individualism and may choose todefer to family or community values in decision-making.

4. Nurses ensure that nursing care is provided with theperson’s informed consent. Nurses recognize andsupport a capable person’s right to refuse orwithdraw consent for care or treatment at any time.

5. Nurses are sensitive to the inherent power differentialsbetween care providers and those receiving care. Theydo not misuse that power to influence decision-making.

6. Nurses advocate for persons in their care if they believethat the health of those persons is being compromisedby factors beyond their control, including the decision-making of others.

7. When family members disagree with the decisionsmade by a person with health-care needs, nurses assistfamilies in gaining an understanding of the person’sdecisions.

8. Nurses respect the informed decision-making ofcapable persons, including choice of lifestyles ortreatment not conducive to good health.

9. When illness or other factors reduce a person’scapacity for making choices, nurses assist or supportthat person’s participation in making choicesappropriate to their capability.

C. PROMOTING AND RESPECTING INFORMED DECISION-MAKINGNurses recognize, respect and promote a person’s right to be informed and make decisions.



10. If a person receiving care is clearly incapable ofconsent, the nurse respects the law on capacityassessment and substitute decision-making in his orher jurisdiction (Canadian Nurses Protective Society[CNPS], 2004).

11. Nurses, along with other health-care professionalsand with substitute decision-makers, consider andrespect the best interests of the person receivingcare and any previously known wishes or advancedirectives that apply in the situation (CNPS, 2004).

D. PRESERVING DIGNITYNurses recognize and respect the intrinsic worth of each person.


1. Nurses, in their professional capacity, relate to allpersons with respect.

2. Nurses support the person, family, group,population or community receiving care inmaintaining their dignity and integrity.

3. In health-care decision-making, in treatment and incare, nurses work with persons receiving care,including families, groups, populations andcommunities, to take into account their uniquevalues, customs and spiritual beliefs, as well astheir social and economic circumstances.

4. Nurses intervene, and report when necessary4, whenothers fail to respect the dignity of a personreceiving care, recognizing that to be silent andpassive is to condone the behaviour.

5. Nurses respect the physical privacy of persons byproviding care in a discreet manner and byminimizing intrusions.

6. When providing care, nurses utilize practicestandards, best practice guidelines and policiesconcerning restraint usage.

7. Nurses maintain appropriate professional boundariesand ensure their relationships are always for thebenefit of the persons they serve. They recognize thepotential vulnerability of persons and do not exploittheir trust and dependency in a way that mightcompromise the therapeutic relationship. They do notabuse their relationship for personal or financial gain,and do not enter into personal relationships (romantic,sexual or other) with persons in their care.

8. In all practice settings, nurses work to relieve pain andsuffering, including appropriate and effective symptomand pain management, to allow persons to live withdignity.

9. When a person receiving care is terminally ill or dying,nurses foster comfort, alleviate suffering, advocate foradequate relief of discomfort and pain and support adignified and peaceful death. This includes support forthe family during and following the death, and care ofthe person’s body after death.

10. Nurses treat each other, colleagues, students and otherhealth-care workers in a respectful manner, recognizingthe power differentials among those in formalleadership positions, staff and students. They workwith others to resolve differences in a constructive way.

4 See footnote 2




1. Nurses respect the right of people to have controlover the collection, use, access and disclosure oftheir personal information.

2. When nurses are conversing with persons receivingcare, they take reasonable measures to preventconfidential information in the conversation frombeing overheard.

3. Nurses collect, use and disclose health informationon a need-to-know basis with the highest degree ofanonymity possible in the circumstances and inaccordance with privacy laws.

4. When nurses are required to disclose information fora particular purpose, they disclose only the amountof information necessary for that purpose andinform only those necessary. They attempt to do soin ways that minimize any potential harm to theindividual, family or community.

5. When nurses engage in any form of communication,including verbal or electronic, involving a discussionof clinical cases, they ensure that their discussion ofpersons receiving care is respectful and does notidentify those persons unless appropriate.

6. Nurses advocate for persons in their care to receiveaccess to their own health-care records through atimely and affordable process when such access isrequested.

7. Nurses respect policies that protect and preservepeople’s privacy, including security safeguards ininformation technology.

8. Nurses do not abuse their access to information byaccessing health-care records, including their own, afamily member’s or any other person’s, for purposesinconsistent with their professional obligations.

9. Nurses do not use photo or other technology tointrude into the privacy of a person receiving care.

10. Nurses intervene if others inappropriately access ordisclose personal or health information of personsreceiving care.

E. MAINTAINING PRIVACY AND CONFIDENTIALITYNurses recognize the importance of privacy and confidentiality and safeguard personal, family

and community information obtained in the context of a professional relationship.




1. When providing care, nurses do not discriminate onthe basis of a person’s race, ethnicity, culture,political and spiritual beliefs, social or maritalstatus, gender, sexual orientation, age, healthstatus, place of origin, lifestyle, mental or physicalability or socio-economic status or any otherattribute.

2. Nurses refrain from judging, labelling, demeaning,stigmatizing and humiliating behaviours towardpersons receiving care, other health-careprofessionals and each other.

3. Nurses do not engage in any form of lying,punishment or torture or any form of unusualtreatment or action that is inhumane or degrading.They refuse to be complicit in such behaviours. They

intervene, and they report such behaviours.

4. Nurses make fair decisions about the allocation ofresources under their control based on the needs ofpersons, groups or communities to whom they areproviding care. They advocate for fair treatment andfor fair distribution of resources for those in theircare.

5. Nurses support a climate of trust that sponsorsopenness, encourages questioning the status quoand supports those who speak out to addressconcerns in good faith (e.g., whistle-blowing).

F. PROMOTING JUSTICENurses uphold principles of justice by safeguarding human rights, equity and fairness and by

promoting the public good.




1. Nurses, as members of a self-regulating profession,practise according to the values and responsibilitiesin the Code of Ethics for Registered Nurses and inkeeping with the professional standards, laws andregulations supporting ethical practice.

2. Nurses are honest and practise with integrity in allof their professional interactions.

3. Nurses practise within the limits of theircompetence. When aspects of care are beyond theirlevel of competence, they seek additionalinformation or knowledge, seek help from theirsupervisor or a competent practitioner and/orrequest a different work assignment. In themeantime, nurses remain with the person receivingcare until another nurse is available.

4. Nurses maintain their fitness to practise. If they areaware that they do not have the necessary physical,mental or emotional capacity to practise safely andcompetently, they withdraw from the provision ofcare after consulting with their employer or, if theyare self-employed, arranging that someone elseattend to their clients’ health-care needs. Nursesthen take the necessary steps to regain their fitnessto practise.

5. Nurses are attentive to signs that a colleague is unable,for whatever reason, to perform his or her duties. Insuch a case, nurses will take the necessary steps toprotect the safety of persons receiving care.

6. Nurses clearly and accurately represent themselveswith respect to their name, title and role.

7. If nursing care is requested that is in conflict with thenurse’s moral beliefs and values but in keeping withprofessional practice, the nurse provides safe,compassionate, competent and ethical care untilalternative care arrangements are in place to meet theperson’s needs or desires. If nurses can anticipate aconflict with their conscience, they have an obligationto notify their employers or, if the nurse is self-employed, persons receiving care in advance so thatalternative arrangements can be made.

8. Nurses identify and address conflicts of interest. Theydisclose actual or potential conflicts of interest thatarise in their professional roles and relationships andresolve them in the interest of persons receiving care.

9. Nurses share their knowledge and provide feedback,mentorship and guidance for the professionaldevelopment of nursing students, novice nurses andother health-care team members.

G. BEING ACCOUNTABLENurses are accountable for their actions and answerable for their practice.



1. Glossary of Terms

2. Applying Professional Standards in Practice

3. CRNBC Resources

4. Guidelines for Resolving Professional Practice Problems

5. Guidelines for Taking Action on Nurses’ Unacceptable Behaviour

APPENDICES



Assignment: Allocation of clients or client care activitiesamong care providers in order to meet client care needs.Assignment occurs when the required care falls within theemploying agency’s policies and role descriptions andwithin the regulated health care provider’s scope ofpractice. Assignment to unregulated care providers occurswhen the required care falls within the employing agency’spolicies and role description.

Client: An individual, family, group, population or entirecommunity who requires nursing expertise. In some clinicalsettings, the client may be referred to as a patient orresident.

Competence: The integration and application of knowledge,skills, attitude and judgment required for safe, ethical andappropriate performance in an individual’s nursing practice.

Delegation: Sharing authority with other health careproviders to provide a particular aspect of care. Delegationamong regulated care providers occurs when an activity iswithin the scope of practice of the delegating professionaland outside the scope of the other professional (includesboth the right to order a restricted activity and carrying outthe restricted activity). Delegation to unregulated careproviders occurs when the required task is outside the roledescription and training of the unregulated care provider.

Ethical: The fundamental disposition of the nurse towardwhat is good and right and action toward what the nurserecognizes or believes to be the best good in a particularsituation (Benner, Tanner and Chesla, 1996).17

Evidence-based practice: Practice based on successfulstrategies that improve client outcomes and are derivedfrom a combination of various sources of evidence,including client perspective, research, national guidelines,policies, consensus statements, expert opinion and qualityimprovement data.

Fitness to practice: All the qualities and capabilities of anindividual relevant to his or her capacity to practise as anurse, including, but not limited to, any cognitive, physical,psychological or emotional condition, or a dependence onalcohol or drugs, that impairs his or her ability to practisenursing.

Health care team: Clients, families, health careprofessionals, paraprofessionals, students, volunteers andothers who may be involved in providing care.

Indicator: Indicators illustrate how a Professional Standardis applied and met. Indicators provide specific criteria thatare used, when applicable, to measure the actualperformance of an individual nurse.

Nurse practitioner: Registered nurses who have achievedthe competencies required for additional registration as anurse practitioner with CRNBC. The competencies requiredof nurse practitioners are usually achieved throughgraduate nursing education and substantial nursingpractice experience. Nurse practitioners provide health careservices from a holistic nursing perspective combined witha focus on the diagnosis and treatment of acute and chronicillnesses, including prescribing medications.

Nursing science: Knowledge (e.g., concepts, constructs,principles, theories) of nursing derived from systematicobservation, study and research.

Professional conduct: Behaving in a way that upholds theprofession. This includes, but is not limited to, practising inaccordance with relevant legislation, CRNBC Standards ofPractice and the Canadian Nurses Association Code ofEthics for Registered Nurses.

Scope of practice: Activities nurses are educated andauthorized to perform as set out in the Nurses (Registered)and Nurse Practitioners Regulation under the HealthProfessions Act and complemented by standards, limits andconditions established by CRNBC.

Standard: A desired and achievable level of performanceagainst which actual performance can be compared. Itprovides a benchmark below which performance isunacceptable. The Professional Standards are statementsabout levels of performance that nurses in B.C. are requiredto achieve in their practice and represent the criteria againstwhich the performance of all nurses in the province ismeasured.

APPENDIX 1 : GLOSSARY OF TERMS

17 Benner, P.E., Tanner, C.A., & Chesla, C.A. (1996). Expertise in nursing practice: Caring, clinical judgment and ethics. New York: Springer.



Use the Professional Standards to support your ownnursing practice and to assist your agency to developsystems that support nurses to meet CRNBC Standardsof Practice.

AS AN INDIVIDUAL NURSE, USE THEPROFESSIONAL STANDARDS TO: - assess your practice as part of meeting continuing

competence requirements;- define and resolve professional practice problems

(see Appendix 4);- advocate for improvements to promote quality client

care and nursing practice;- determine what role you can take in program and

policy development and evaluation;- articulate nursing’s contributions to the health of

clients and to the work of multidisciplinary teams;and

- inform others about the professional practice ofnursing.

Examples of situations in which the ProfessionalStandards may assist you:- if you are concerned about a client and others are not

taking your concerns seriously, you are meeting theProfessional Standards by pursuing your concernsand advocating for resolution through the appropriatechannels on behalf of your client;

- if you believe there are practice concerns on yourunit, use the Professional Standards to articulate thenature and seriousness of the concerns and bringthem forward for action and resolution;

- if you are asked to provide information about a clientto someone not involved in his or her care, use theProfessional Standards to support your decisionregarding release of this information;

- if other nurses or health care providers tell you to dosomething you know you are not competent to do,suggesting that they will be accountable, use theProfessional Standards to support your position thatonly you can be accountable for your practice; and

- if you are concerned that a client has not beenprovided with enough information to make aninformed choice, use the Professional Standards tosupport your actions to ensure the client receivesadequate information to make an informed choice.

TO IMPROVE NURSING PRACTICE WITHIN YOURAGENCY, USE THE PROFESSIONAL STANDARDS:- as a framework to identify agency strengths and areas

for improvement (CRNBC Practice Support can helpwith this process - see Appendix 3); and

- to develop systems that create more effective practiceenvironments, including providing essential supportsystems so that nurses are able to meet theProfessional Standards.

Examples of ways in which the Professional Standardscan be used in clinical practice include developing,modifying and evaluating: - specific expectations for practice that are relevant to

the clinical area, role and setting; andclient documentation systems.

Examples of ways in which the Professional Standardscan be used in education include developing, modifyingand evaluating:- education programs;- orientation programs;- preceptorship and mentorship programs; and- nursing rounds.

Examples of ways in which the Professional Standardscan be used in administration include developing,modifying and evaluating:- role descriptions;- policies and procedures; and- performance appraisal tools.

Examples of ways in which the Professional Standardscan be used in research include developing, modifyingand evaluating:- quality improvement initiatives; and- evidence-based decision support tools.

APPENDIX 2 : APPLYING PROFESSIONAL STANDARDS IN PRACTICE



EXEMPLARS

Clinical PracticeNurses understand that the Professional Standardsapply to all registered nurses, licensed graduate nursesand nurse practitioners and must, therefore, be quitegeneric. However, the Professional Standards can alsobe a framework for the development of more specificcriteria. For example, a patient care coordinator on amedical unit in a small rural hospital reviewed Standard2: Specialized Body of Knowledge and Standard 3:Competent Application of Knowledge and identifiedseveral criteria related to each indicator that would bespecific to the medical unit. She developed a draft andposted it for feedback from other nurses on the unit.After several drafts, unit-specific practice expectationswere circulated. These criteria were then used todevelop an orientation program for the unit. The sameprocess could be applied to any clinical area.

EducationNurses working in community mental health identifiedthe need for additional information about resolvingethical dilemmas in their practice area. They informedtheir clinical educator who used Standard 4: Code ofEthics as a starting place for the development ofinservice education sessions. These inservices weregrounded in the Canadian Nurses Association Code ofEthics for Registered Nurses, but were tailored to meetthe specific learning needs of these nurses usingclinical examples from their practice in communitymental health.

AdministrationIn an urban community hospital, a nurse consultantwas hired to develop nursing practice expectationsconsistent with the hospital’s mission, values andstrategic plan. The consultant involved managers andnurse representatives from each area of practice in thehospital in a series of workshops in which they usedthe Professional Standards to describe their practice.

Then they moved on to define expectations for theirpractice in each clinical area. Working documents withunit-specific practice criteria were then circulated to allnurses for feedback. The managers met with theconsultant to make sure the content was valid andconsistent across clinical areas. The criteria were thenfinalized and work began on the development ofcompetency-based education modules and a newperformance appraisal tool.

ResearchRecognizing the importance of research findings demon-strating the impact of the practice environment on nurseand patient outcomes, a university-affiliated nurseresearcher contacted a nurse administrator at a large terti-ary care hospital to propose a collaborative research proj-ect. Nurses within the hospital reported they were, attimes, unable to provide care in a manner that met theProfessional Standards, in particular because of a lack ofnursing leadership within their programs. The nurseadministrator indicated that the hospital planned to re-introduce head nurses on several units. She and thenurse researcher agreed that this presented an idealopportunity to study the difference in nurse and patientoutcomes before and after implementation of this change.They planned to use the Professional Standards to pro-vide a framework for collecting and reporting some of thedata.



WWW.CRNBC.CA

Use CRNBC’s website to view or print CRNBC documents,access library services, register for workshops andteleconferences, and access the latest CRNBC news andinformation.

PUBLICATIONS

CRNBC publishes a variety of publications that cansupport you in your practice. They are available toregistrants at no cost and can be downloaded from theCRNBC website www.crnbc.ca

Practice StandardsCRNBC’s Practice Standards are a series of shortdocuments that set out requirements related to specificaspects of nurses’ practice. Like Professional Standards,Practice Standards guide and direct nursing practice.Topics in the series include administration ofmedications, assignment between nurses,confidentiality, consent, documentation, duty to providecare, duty to report and nurse-client relationships.

Scope of Practice StandardsScope of Practice Standards set out standards, limitsand conditions related to the scope of practice ofregistered nurses and nurse practitioners. CRNBC limitson scope of practice specify what nurses are notpermitted to do. CRNBC conditions on scope of practiceset out the circumstances under which nurses may carryout an activity.

Practice Support BooksThis series of publications provides in-depth informationon topics related to the practice of nurses. Topicsinclude administration of medications, nurse-clientrelationships, documentation, confidentiality, andassigning and delegating. Available in the NursingStandards section of the CRNBC website www.crnbc.ca

Continuing CompetenceA Short Guide to Meeting Continuing CompetenceRequirementsStep-by-step guide to assist you to meet the continuingcompetence requirements for registration renewal.

Continuing Competence JournalKeep track of professional development activities.

Continuing Competence ChecklistTo ensure that all continuing competence requirementshave been met.

Online Tutorial Examples of how nurses from different practice areashave chosen to complete their personal practice review.It shows how to make the personal practice reviewrelevant to your own practice.

OTHER RESOURCESAssisting Nurses with Significant Performance ProblemsAssists managers and other resource people who workwith nurses experiencing significant performanceproblems. It presents a framework for approaching thiswork and offers practical suggestions.

Competencies in the Context of Entry-level RegisteredNurse Practice in British ColumbiaProfiles the practice of a newly graduated registerednurse and lists the generic entry-level competenciesexpected of a new graduate.

Fitness to PracticeProvides easy-to-understand information about stressorsin the work environment, emotional, physical andbehavioural responses to chronic stress, and healingfrom chronic stress. It includes a self-assessment toolfor chronic stress and a list of additional resources.

APPENDIX 3 : CRNBC RESOURCES


http://www.crnbc.ca/Standards/ProfessionalStandards/Pages/PracticeStandards.aspx

http://www.crnbc.ca/Standards/ScopePractice/Pages/Default.aspx

http://www.crnbc.ca/Registration/ContCompetence/Pages/Default.aspx



http://www.crnbc.ca/Standards/Workplace/Pages/Default.aspx

http://www.crnbc.ca/PracticeSupport/CoursesWorkshops/tutorials/Pages/Default.aspx

http://www.crnbc.ca/standards/professionalstandards/pages/crnbcresources.aspx



Profile of a Newly Graduated Registered NurseProvides an overview of the practice of new graduateregistered nurses. The practice profile is based onCRNBC’s Professional Standards and highlights basiccompetencies that graduates of B.C. nursing programsare expected to demonstrate.

Workplace and Quality Practice Environments Answers to question related to Standards of Practice thatcome up in the workplace and provides informationabout quality practice environments.

PRACTICE SUPPORT

Individual and Group Consultation

Practice support is available to you from nursingpractice advisors in offices throughout B.C. or fromnursing practice consultants in the Vancouver office.These registered nurses work on a confidential basis toassist you to resolve professional practice problemsand workplace issues affecting your ability to meetStandards of Practice. Consultations are providedthrough telephone, individual appointments and on-site visits.

Consultation and education are also available on issuesassociated with fitness to practice, such as addiction ormental health, or conflicts that may affect practice.

Contact CRNBC Practice Support at 604.736.7331 (ext. 332) or 1.800.565.6505 (Canada). [email protected] Contact information for CRNBC’snursing practice advisors can be found on the CRNBCwebsite www.crnbc.ca

WORKPLACE REPRESENTATIVE PROGRAM ANDSTUDENT REPRESENTATIVE PROGRAM

In most health care agencies, CRNBC workplacerepresentatives are available to assist nurses tounderstand and use CRNBC’s Standards of Practice.Similarly, in B.C. schools of nursing, studentrepresentatives can help nursing students becomeaware of how the Standards should guide their practice.These volunteers can put you in touch with CRNBC’sregional nursing practice advisors and other resourcesthat support good nursing practice.

Contact the workplace representative or the studentrepresentative directly in your agency or school orcontact CRNBC Practice Support at 604.736.7331 (ext. 332) or 1.800.565.6505 (Canada). E-mail [email protected]

LIBRARY SERVICES

Library and reference services are available to youwherever you live in B.C. The CRNBC Helen RandalLibrary has one of the best collections of nursing books,journals and audiovisual materials in Canada. Mostitems can be borrowed by phone, mail, e-mail or in person from the library, which is located at 2855 Arbutus Street, Vancouver. Other services includeinter-library loans, photocopying and online journal andcatalogue searches. See CRNBC’s website for fulldetails.

For general enquiries, telephone 604.736.7331 (ext. 456) or 1.800.565.6505 (Canada).For reference enquiries, telephone 604.736.7331 (ext. 119) or toll-free 1.800.565.6505. E-mail [email protected]



http://www.crnbc.ca/Standards/Workplace/Pages/Default.aspx

http://www.crnbc.ca/registration/rnapplication/bcen/Pages/Default.aspx



WORKSHOPS AND COURSES

CRNBC’s workshops and courses focus on theprofessional aspects of nursing, such as clinicaldecision making in nursing practice, understandingregistered nurses’ scope of practice and communicationin nursing. CRNBC provides learning through webmodules, online courses and blende learning thatincorporates self-learning and workshops. Learningprograms can also be custom designed for specificgroups and work settings.

Contact CRNBC Education Services and Communicationsat 604.736.7331 (ext. 341) or 1.800.565.6505 (Canada).E-mail [email protected]

PROFESSIONAL CONDUCT REVIEW

The primary focus of CRNBC’s Professional ConductReview Program is protection of the public. Assistance isavailable if anyone is concerned about the practice orconduct of a CRNBC practising registrant. CRNBC’sNursing Concerns Coordinator works to help resolvethese concerns.

Contact CRNBC’s Nursing Concerns Coordinator at 604.736.7331 (ext. 202) or 1.800.565.6505 (Canada).



As a nurse, you face diverse and complex problems thathave an impact on your practice. At the same time, youare held accountable and responsible for makingdecisions that are consistent with safe, appropriate andethical nursing practice. The process described belowcan be used as a resource by nurses in all settings tohelp identify and resolve problems that affectprofessional practice.

WHAT IS A PROFESSIONAL PRACTICE PROBLEM?

A professional practice problem is any problem orsituation that:

• interferes with a nurse’s ability to practise in amanner consistent with CRNBC’s Standards ofPractice, workplace policies or procedures, or otherrelevant standards and guidelines;

• has or could put clients at risk;

• is beyond the ability of an individual nurse to resolve.

NURSES AND EMPLOYERS EACH HAVERESPONSIBILITIES IN THE WORKPLACE.

Nurses are accountable to:

• clients for any actions or non-actions;

• the public, through CRNBC, for maintaining acceptedstandards of practice;

• the employer for working to accepted standards and forusing appropriate routes of communication to informthe employer when unable to meet those standards.

EMPLOYERS ARE RESPONSIBLE FOR ENSURINGTHAT:• action is taken to examine situations and resolve

problems once they have been informed about them;

• there is a sufficient number of competent nursing staff;and

• there are adequate resources and support services sothat nurses are able to meet the Standards of Practice.

HOW CAN THESE GUIDELINES HELP RESOLVEPROFESSIONAL PRACTICE PROBLEMS?

These guidelines can be used to help you confirm,communicate, document and resolve professionalpractice problems. They can assist you to protect clientsfrom harm and ensure that they receive safe andappropriate care. CRNBC nursing practice consultantsand regional nursing practice advisors can assist you toclarify any of the four steps in this process.

STEP 1 : CONFIRM THE PROBLEM

APPENDIX 4 : GUIDELINES FOR RESOLVING PROFESSIONAL PRACTICE PROBLEMS

E X A M P L E S O F P R O F E S S I O N A L P R A C T I C E P R O B L E M S

• staff that is inadequate in number, education orexperience

• lack of written policies or guidelines to providedirection for nursing practice

• lack of required medical or other health careprofessionals

• conflict between professionals

• communication problems

• lack of supplies or equipment



STEP 1 : CONFIRM THE PROBLEMThese questions can help to identify and confirm theproblem:

Yes No

� � Does the problem present a risk to clients?What are the risks or effects on client care?

� � Does the problem conflict with standards,guidelines, policies/procedures?

� � Does the problem make it difficult or impossi-ble to practise according to policies or proce-dures, care plans, CRNBC’s Standards ofPractice and/or the Canadian NursesAssociation Code of Ethics for RegisteredNurses?

� � Does the problem interfere with your ability topractise competently?

� � Does the absence of policies/procedures/guidelines contribute to this problem?

� � Are other factors associated with this problem?If so, what are they (e.g., people, situations,settings, shifts/times)?

� � Does the problem occur frequently?

� � Do other nurses have similar concerns?

If you answered “yes” to most of these questions, youmay have a professional practice problem. You maywish to consult a CRNBC nursing practice consultant orregional nursing practice advisor on a confidentialbasis.

If you answered “no,” your problem is not likely aprofessional practice problem. It may be a labourrelations issue or relate to employment conditions suchas hours of work, vacation, etc. You may wish to consultwith your manager and, if appropriate, your unionrepresentative.

STEP 2: COMMUNICATE THE PROBLEM

Once it is clear that you are facing a professional practiceproblem, communicate the problem so that it can beexamined and action taken:

• First, contact your manager or person to whom youreport to discuss the problem.

• Explain what CRNBC Standards or other standards arenot being met and what effect this is having on clientsor how the problem prevents you from practisingaccording to these standards.

• Be specific and factual, include all relevant information.

• Offer to work together to resolve the problem.

Following your discussion, record in writing everythingyou verbally reported and the response received.

STEP 3: DOCUMENT THE PROBLEM

When documenting the problem:

• Treat all documentation as confidential.

• Use the proper form for this purpose. If there is no suchform in your workplace, write it as a letter or a memo(see examples on page 34).

• Begin with the date then indicate the name and title ofthe person to whom you are sending thedocumentation.

• Start with a general opening statement such as: “Thisis a follow-up to our discussion of the professionalpractice problem . . . ”

• Describe the problem in detail: date, time, place, whowas involved (use initials for client names), whathappened, how it affected/impacted client care, whatstandards were not met.

• Describe what your actions were in relation to theproblem and proposed solutions.

• Request a written response by a specific date (be surethe date is reasonable for the problem).

• Sign your name. Keep a copy for your records.

• If you do not receive a response by the

specified date, ask what progress is being made. Ifthe problem is not being addressed:

- Send a second memo or letter to the same person.State that this is in follow-up to your earlier memo.Restate the problem or attach the first memo.Request assurance that the problem will beaddressed right away.

- Forward copies to all levels of administration in theworkplace and note this by writing “c.c. Jane Doe,John Doe” at the bottom of the last page of thememo.

- Keep a copy for your records.

STEP 4: RESOLVE THE PROBLEM

Most professional practice problems can be resolvedwithin the workplace. Usually, you will receiveresponses to your letter or memo either in writing orverbally. Often, a meeting will be arranged. During themeeting:

• Listen with an open mind to the manager’sperspective of the problem and response to it. Payattention to any new information the managerprovides.

• Be prepared to work together to resolve the problem.Some negotiation and compromise may be necessaryas long as clients are not in danger.

• If the problem and your concerns are not beingaddressed to your satisfaction, say so. Be prepared totake your concerns further, indicating why you thinkfurther action is necessary. If the problem has notbeen resolved, consider repeating the necessarysteps and addressing the problem with the next levelof management. If the problem remains unresolvedand you believe you have exhausted all avenues forresolution within your workplace, request formalinvolvement from CRNBC. The College has a legalmandate to ensure that nurses maintain standards ofpractice and provide safe and appropriate nursingcare.

• Review documents to assure accuracy and clientconfidentiality.

• Write a letter asking CRNBC for assistance. Outline the

steps you have taken to confirm, communicate,document, and resolve the problem within yourworkplace. Include dates and copies or a description ofall the responses and results received.

• Arrange a meeting with the senior manager in yourworkplace to discuss the letter to CRNBC and give themanager a copy.

• Forward your letter and all documentation in anenvelope marked “Confidential” to the CRNBCRegistrar/CEO, 2855 Arbutus Street, Vancouver, BC V6J3Y8. Keep a copy of everything for your records.

Once formally involved, CRNBC staff will contact you andthe senior manager to assist in resolving the problem.CRNBC may involve other appropriate organizations suchas other professional regulatory organizations, governmentministries and health authorities.



S A M P L E L E T T E R

CONFIDENTIAL

Day/month/year

Jane Doe, RNManager, Program WXYZ Health RegionAnywhere, BC

Dear Ms. Doe:This letter is a follow-up to our discussion today of theprofessional practice problem related to communicationdifficulties among . . .

S A M P L E M E M O

CONFIDENTIAL

To: Donald Black, RN, Manager, Program XFrom: Jane Doe, RNDate: Day/month/yearSubject: Professional Practice Problem

This memo is a follow-up to our discussion today of theprofessional practice problem related to inadequatestaffing . . .



PROFESSIONAL CONDUCT

The professional conduct of all CRNBC registrants isguided by the Health Professions Act, Nurses (Registered)and Nurse Practitioners Regulation, CRNBC Bylaws andStandards of Practice.

CRNBC is responsible for establishing and enforcingStandards of Practice so that the public receives safeand ethical nursing care from competent nurses. WhileCRNBC has the statutory responsibility to take actionwhen a registrant’s ability to provide safe andappropriate nursing care is questioned, all registrantshave a responsibility to report unsafe practice orunacceptable behaviour18 to the regulatory body incertain situations.

The following guidelines can help you to meet yourlegal and ethical obligations to protect the public bothwithin and beyond the workplace.

STEP 1 : DEFINING UNACCEPTABLE BEHAVIOUR

Unacceptable behaviour may be unethical behaviour,impaired practice or incompetence. Incompetence is apattern of behaviour that demonstrates a failure tomeet the Standards of Practice because of lack ofability, capacity or fitness to practise. It results fromrepeatedly making the same or similar mistakes, notfrom an isolated act or a single error.

Nurses demonstrating unacceptable behaviour mayhave no idea of wrong doing. They may rationalize thatwhat they are doing is all right, or they may attempt tocover up something that jeopardizes client welfare.

The following questions can help you assess thebehaviour of a nurse:

Yes No

❑ ❑ Is the nurse failing to provide safe and appro-priate nursing care?

❑ ❑ Does this behaviour involve theft, falsificationof records, or a breach of accepted ethicalstandards in some other way?

❑ ❑ Has there been a pattern of questionablebehaviour and is it likely to continue?

❑ ❑ Is the nurse unable or unwilling to recognizeand correct the problem behaviour?

❑ ❑ Have clients been harmed by this behaviour orare they likely to be in the future?

❑ ❑ Is there documentation or other evidence ofproblem behaviour?

If you answered “yes” to any of these questions, youshould take action.

STEP 2: DECIDING TO TAKE ACTION ONUNACCEPTABLE BEHAVIOUR

Consider whether the most appropriate action is for youto discuss your concerns directly with the nurse. This isoften a difficult decision and the following questions mayhelp you decide what to do:

• What would you want done if you were the nurse withunacceptable behaviour?

• What is your relationship with the nurse involved (e.g.,credibility, reporting relationship, personalrelationship)?

18 Nurses are required under the Health Professions Act to report situations in which a health professional’s fitness to practise, competence to practise or ethicalconduct may pose a risk to the public. More information is available in the CRNBC Practice Standard Duty to Report.

APPENDIX 5 : GUIDELINES FOR TAKING ACTIONON NURSES’ UNACCEPTABLE BEHAVIOUR

http://www.crnbc.ca/NursingPractice/Requirements/PracticeStandards.aspx



• What are the usual procedures for dealing with theseissues in your workplace?

• Can you discuss the facts of the situation objectivelyand without emotion?

• Can you create an opportunity to discuss thebehaviour privately with the nurse?

• What is the likelihood of the nurse understanding andresponding to what you say?

If you discuss your concerns directly with the nurse andthe matter is resolved, it may not be necessary for you totake further action. If your concerns are not addressedor if you decide that it is not wise for you to discuss yourobservations and concerns directly with the nurse or if areport is required, then you should use the reportingmechanisms in your workplace so others can takeaction. Talk to your manager or the person to whom youreport.

STEP 3: REPORTING UNACCEPTABLE BEHAVIOURTO YOUR MANAGER

Document your concerns and discuss them with yourmanager. When documenting and reportingunacceptable behaviour:

• Describe the unacceptable behaviour in detail. Givethe date, time, place, who was involved (use initialsfor client names), what happened, how it affectedclient care, what standards were not met.

• Obtain support. Consult resource people in theworkplace or call a CRNBC nursing practice consultantto assist on a confidential basis regarding appropriatestandards of practice (this is not reporting a colleague;you don’t have to name the nurse).

• Sign your name. Anonymous reporting is less credible.

• Treat all documentation as confidential.

• Request acknowledgment that your information hasbeen received and assurance that the problem will beinvestigated and appropriate action taken.

• Be patient, as long as clients are not in danger, asthese problems often require time to resolve.

• If the unacceptable behaviour has not been dealt withappropriately within a reasonable time frame, informyour manager that you are considering reporting toCRNBC.

M I N I M I Z I N G C O N F L I C T I N G F E E L I N G SA B O U T R E P O R T I N G

Nurses may have feelings of conflict betweenloyalty to the profession and clients, and loyaltyto colleagues and the employer. These feelingsmay discourage appropriate action becausenurses may believe they are letting colleaguesdown. The following practices can prevent thissituation from occurring and minimize thefeelings of conflict:

• focus on decreasing risks to client safety, noton penalizing nurses;

• use CRNBC’s Standards of Practice to evaluateperformance based on measurableexpectations;

• adhere to principles of fairness, dignity,respect, and honesty in the workplace; and

• maintain confidentiality and share informationabout the situation only with those who requireit.



STEP 4: REPORTING UNACCEPTABLE BEHAVIOURTO CRNBC

When to Report to CRNBC

Reporting to CRNBC is required when there is a reasonto believe that there is a danger to the public if thenurse continues to practise.

Who to Contact at CRNBC

You will receive confidential guidance about yourconcerns by contacting:

Nursing Concerns CoordinatorCRNBC Registration, Inquiry and Discipline2855 Arbutus StreetVancouver, BC V6J 3Y8604.736.7331 (ext. 202)1.800.565.6505 (ext. 202)

The Nursing Concerns Coordinator will work with you andassist you in resolving your concerns. Together, you willlook at various options for action. Your identity duringthis consultation process is kept confidential. Should youdecide to submit a complaint, you will be asked toprovide detailed information about your complaint (seebelow) and you may be asked to participate in theprocess to resolve the concerns.

How to Submit a Complaint

A letter of complaint is most useful when it includes theinformation listed below. If you do not have all of theinformation or access to it, do not let this stop you fromsubmitting the complaint.

• Full name and, if possible, registration number of thenurse whose behaviour is unacceptable.

• A detailed description of the unacceptable behaviourwith examples of specific incidents that support thecomplaint. For each incident provide date, time, place,who was involved, names of nurses and others whohave direct knowledge of the behaviour, whathappened, how it affected client care, as well asspecific standards, workplace policies, procedures orguidelines that have not been met.

• Copies of documents19 supporting the complaint. Thismay include copies of incident reports, chart pages,narcotic records, performance appraisals or otherreports of nursing performance, written statementsfrom co-workers, other staff, clients or clients’relatives.

• An outline of any action taken by the employer andothers since the unacceptable behaviour was firstnoticed, and a description of the nurse’s responses tothose actions.

• The date the nurse started working for the employerand, if applicable, when the employment wasterminated.

Complaints should be submitted to:

DirectorCRNBC Registration, Inquiry and Discipline 2855 Arbutus StreetVancouver, BC V6J 3Y8

19 Appropriate permission to release documents to CRNBC must be obtained prior to submitting them.



WHEN A COMPLAINT IS RECEIVED

When CRNBC receives a complaint, it may be dealtwith through consensual resolution, or it may requirefurther investigation and possible inquiry.

Once a complaint has been accepted by the CRNBCInquiry Committee, CRNBC may negotiate directly withthe nurse in question to determine appropriate actionto address the concern.

Alternatively, CRNBC may gather evidence and hold aformal hearing before the Discipline Committee. Thismethod is judicial in nature, similar to a courtproceeding.

Both processes are designed to deal with complaintsin a way that is effective and fair to all concerned, tocarry out CRNBC’s responsibility to the public, and tomaintain the integrity and standards of the profession.

As far as is possible, CRNBC will let you know aboutthe outcomes of action related to the complaint youhave submitted.

If you have questions regarding the procedures forsubmitting a complaint, contact CRNBC’s NursingConcerns Coordinator at 604.736.7331 (ext. 202) or 1.800.565.6505 (ext. 202).

S A M P L E L E T T E R

CONFIDENTIAL

Day/Month/Year

Jane DoeAnywhere BC

Dear Director, Registration, Inquiry and Discipline:

This letter is a submission of a formal complaint concern-ing the professional practice of . . .- Give full name of nurse and registration number (if

known).- State the nurse’s employment history, including start

date and dates of performance appraisals (if known).

Provide a factual description of incidents causing practiceconcerns . . . - Identify what standards, policies, procedures or guide-

lines were/are not being met. - Indicate what supporting documentation is available to

support the complaint.

Outline actions taken to address the concern and theresponse to these actions . . .- Where applicable include the date the nurse

started suspension, was terminated, etc.

Sincerely,

Signature(note: an original signature is required in order forCRNBC to follow up the complaint)

Jane Doe



NOTES

2855 Arbutus St.Vancouver, British ColumbiaCanada V6J 3Y8Tel: 604.736.7331 Toll-free: 1.800.565.6505 (Canada)www.crnbc.ca

http://www.crnbc.ca

128 Professional Standards

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