self-study guide - OIIQ · The purpose of this self-study guide is to simplify the professional...

to the code of ethics and other legal and ethical considerations for quebec nurses

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Note February, 2016

Appendix I – Code of Ethics of Nurses Since the publication of the Self-Study Guide, a new version of the Code of Ethics of Nurses has come into effect, on October 22, 2015. Although the Guide has not been updated, the information it contains remains current and valid. Of the sections of the Code referred to in the Self-Study Guide, only sections 18 and 45 have been amended in the new Code of Ethics of Nurses (sections quoted on pages 24, 26 and 42 of the Guide).

Section 18: A nurse shall keep her or his professional knowledge and skills up to date in order to provide care and treatment in accordance with generally accepted standards of practice. A nurse shall practise her or his profession in accordance with generally accepted standards of practice and scientific principles. To that end, she or he shall update and develop her or his professional knowledge and skills.

Section 45:

A nurse shall not be negligent when administering medication administering or adjusting medication or other substances. In particular, when administering medication or other substances, a nurse shall have sufficient knowledge of the medication and abide by the principles and methods applicable to its administration.

Appendix II – Relevant Sections of Acts and the Regulation As for the acts and regulations in Appendix II, only section 15 of the Civil Code of Québec has been amended since the Self-Study Guide was published (section quoted on page 150 of the Guide).

Section 15: Where it is ascertained that a person of full age is incapable of giving consent to care required by his or her state of health and in the absence of advance medical directives, consent is given by his or her mandatary, tutor or curator. If the person of full age is not so represented, consent is given by his or her married, civil union or de facto spouse or, if the person has no spouse or his or her spouse is prevented from giving consent, it is given by a close relative or a person who shows a special interest in the person of full age.


self-studyguide

An English version of the guide has been produced by the OIIQ in this case, to help nurses educated outside Quebec better prepare for the entry-to-practice examination and integrate more easily into the Quebec context.

The Order wishes to remind you, however, that in accordance with the Charter of the French Language, permits may be issued only to those candidates who have sufficient knowledge of French to practise the profession. Otherwise, they must obtain an attes-tation from the Office québécois de la langue française (OQLF) before the OIIQ can issue a permit.

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Production

Publications DepartmentSylvie Couture Department Head

Karine Méthot Production Assistant

Claire Demers Publishing Assistant

Member Services and Communications Department, OIIQ

Graphic design and production

TranslationLes traductions Terry Knowles Inc.

RevisionTeresa Berghello, Lyne de Palma and Susan Young Nursing program coordinators, John Abbott College

Proofreading

Distribution

Ordre des infirmières et infirmiers du Québec 4200 Dorchester Boulevard West Westmount, Quebec H3Z 1V4 Tel.: (514) 935-2501 or 1 800 363-6048 Fax: (514) 935-3770

www.oiiq.org

Legal depositLibrary and Archives Canada, 2010 Bibliothèque et Archives nationales du Québec, 2010 ISBN 978-2-89229-457-6

© Ordre des infirmières et infirmiers du Québec, 20 All rights reserved

Note - In keeping with OIIQ editorial policy, the feminine gender has been used to simplify the text. No discrimination is intended.


Publication Sales

[email protected]

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Les traductions Terry Knowles Inc.

Project ManagersJudith Leprohon, RN, PhD, Scientific Director, OIIQ

Sylvie Truchon, RN, MSc, Syndic, OIIQ

Co-ordination and textsNicole Roger, RN, MSc

Contributors

Contribution to texts and validation of specialized contentProfessional ethicsSylvie Truchon, RN, MSc, Syndic

EthicsMarcelle Monette, RN, PhD, consultant

Legal considerationsMarie Paré, Attorney, consultant

Validation Internal validationMartine Dubé, RN, Master’s candidate, Law and Health Policy, Assistant Syndic, OIIQ

Suzanne Durand, RN, MSc, Graduate Certificate in Bioethics, Director Professional Development and Support Department, OIIQ

Monique Flibotte, RN, MSc, Nursing Consultant, Traineeship and Equivalence Admission, Registrar’s Office, OIIQ

Carole Mercier, RN, MSc, Secretary General, OIIQ

Nancy Lévesque, RN, Graduate Certificate in Nursing, Assistant Syndic, OIIQ

External validation Two groups of nursing graduates from outside Quebec helped validate this guide – the first validated the prototype to test the educational approach and the second validated the final document. These nurses were from Brazil, Ivory Coast, Haiti, Lebanon and Romania.

ConsultationWhen we started work on this guide, a group of nurses responsible for professional integration of nursing graduates from outside Quebec, at college and in clinical settings, helped identify the situations presenting the most difficulty for these nurses with regard to the Code of Ethics of Nurses and other legal and ethical considerations as they apply to nursing in Quebec.

AcknowledgmentsWe wish to thank the Ministère de l’Immigration et des Communautés culturelles for its financial assistance toward the production of this guide and the three nursing program coordinators from John Abbott College for their contribution for the revision of the English version of the document.


table of contentsPreamble 7

Section 1 The Code of Ethics of Nurses .............................................................9

Overview of the Code of EthicsFundamentals Regulation ................................................................................................................. 10 An overview of the contents of the Code .......................................................... 11Reading ............................................................................................................................. 13EXERCISE 1.1 Identifying and applying sections of the Code of Ethics of Nurses ............................................................................................... 13 Answer guide ...................................................................................... 24EXERCISE 1.2 Determining the appropriate professional conduct in situations involving issues related to the Code of Ethics .... 32 Answer guide ...................................................................................... 40

The Professional RelationshipFundamentals Nature of the professional relationship ........................................................... 43 Boundaries of the professional relationship ................................................... 44Reading ............................................................................................................................. 47EXERCISE 1.3 Determining the nature and boundaries of the professional relationship ................................................................ 48 Answer guide ...................................................................................... 51EXERCISE 1.4 Determining the appropriate professional conduct in situations relating to the professional relationship ............... 52 Answer guide ...................................................................................... 58

Professional Independence and Conflicts of InterestFundamentals Professional independence .................................................................................. 61EXERCISE 1.5 Recognizing the elements of professional independence ..................................................................................... 62 Answer guide ...................................................................................... 64

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Fundamentals Conflict of interest .................................................................................................. 65Reading ............................................................................................................................. 67EXERCISE 1.6 Recognizing a conflict of interest .................................................. 67 Answer guide ...................................................................................... 74EXERCISE 1.7 Determining the appropriate professional conduct in situations where there is a risk of a conflict of interest ......... 78 Answer guide ...................................................................................... 86

Section 2 Other Legal Considerations for Quebec Nurses ........................................ 89Fundamentals Legislative framework governing nursing in Quebec .................................. 91 Clients’ rights with respect to health care ....................................................... 91 Nurses’ professional liability ................................................................................ 95Reading ............................................................................................................................. 96EXERCISE 2.1 Identifying and applying acts and regulations ......................... 96 Answer guide ....................................................................................109

Section 3 Other Ethical Considerations for Quebec Nurses ......................................119Fundamentals Ethics .........................................................................................................................121 Personal and professional values .....................................................................121 Definitions of values .............................................................................................122EXERCISE 3.1 Determining values .........................................................................124 Answer guide ....................................................................................129EXERCISE 3.2 Recognizing conflicting values ....................................................131 Answer guide ....................................................................................138EXERCISE 3.3 Determining the appropriate professional conduct in situations involving ethical issues .........................................140 Answer guide ....................................................................................148

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The purpose of this self-study guide is to simplify the professional integra-tion of Internationally Educated Nurses (IEN), by familiarizing them with the Code of Ethics of Nurses and other legal and ethical considerations relating to nursing in Quebec.

Produced with the financial support of the Ministère de l’Immigration et des Communautés culturelles, it is designed to help IENs understand the links between these important dimensions of nursing along with the role of Quebec nurses, in particular with regard to their professional independence.

The teaching approach used in this guide will allow these nurses to apply the main principles governing these specific aspects of the nursing profession in Quebec, and to gradually integrate the underlying knowledge through a variety of role-playing exercises.

This educational guide may also be useful for Quebec nursing students, to help them learn these principles and apply them in their professional practice.

The guide is divided into three sections. The first covers the Code of Ethics of Nurses and looks more specifically at the professional relationship and profes-sional independence and conflicts of interest. The second part deals with other legal considerations, with an emphasis on clients’ rights and nurses’ profes-sional liability. Lastly, the third section addresses other ethical considerations and takes an overall approach, so that readers can make decisions on their professional conduct in different situations in light of the applicable factors relating to the law and professional ethics.

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Section 1

ethicsof Nurses

This threepart section looks at the Code of Ethics of Nurses as it applies to nursing in Quebec.

The first part presents an overview of the Code of Ethics of Nurses. The second and third parts deal with specific ethical aspects concerning the professional relationship and professional independence and conflicts of interest. These aspects were chosen because they are more likely to give rise to questions on the part of nurses from outside Quebec.

Each part also includes roleplaying exercises in which you are asked to identify and apply the relevant sections of the Code of Ethics of Nurses and to determine the appropriate professional conduct in the circumstances.

the Code of

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Overview of thecode of ethics

Fundamentals

regulation

The Code of Ethics of Nurses essentially refers to all the duties and moral obligations specific to a profession, which guide professionals in their everyday relations with the public, clients and other professionals, from the point of view of professional and individual responsibility.

The code of ethics is a keystone of professional legislation in Quebec, setting out the duties and obligations specific to a profession. A code of ethics explains how the members of a profession are to conduct themselves in order to protect the public.

Although it lays out the profession’s ethical ideals, the Code of Ethics of Nursesis first and foremost a regulation. The standards it defines are considered “minimal,” meaning that they are a basic threshold. Consequently, any violation of these professional duties and obligations compromises public protection and can result in sanctions being imposed by the Order’s Disciplinary Council.

The Code presents basic guidelines for nurses in their daily practice. The way in which they are applied will always depend on the nurse’s judgment and the context.

To help nurses understand and apply the sections of the Code, the OIIQ Website has a section devoted to it. Aside from the Code itself, nurses may wish to consult the “Ethics Update” column by the Syndic in each issue of The Journal, looking at ethical issues specific to the profession.

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An overview of the contents of the Code

The Code of Ethics of Nurses comprises two chapters. The first deals with duties toward the public, clients and the profession. It is broken up into 10 divisions, some of which are further subdivided. All in all, this chapter comprises 81 sections dealing with different aspects of the nursing profession. Chapter II presents the final provisions.

Division I Duties inherent to the practice of the professionGeneral provisions �Integrity �Condition liable to impair the quality of care and services �Competence �Professional independence and conflict of interest �Availability and diligence �

This division, in addition to general provisions, deals with nurses’ integrity and competence, their availability and the diligence they must display in practising the profession. In addition, a subdivision is devoted to nurses’ duties and obligations concerning professional independence and conflicts of interest. It also looks at the importance for nurses to practice in a condition that does not impair the quality of care and services.

Division II Relationship between the nurse and the clientRelationship of trust �Secrecy of confidential information �Prohibited behaviour �

This division sets out nurses’ professional duties and obligations concerning the relationship of trust to be established with the client, and steps to be taken to preserve the secrecy of confidential information. It also outlines prohibited behaviour so as to preserve the professional relationship.

Division III Quality of care and servicesInformation and consent �The therapeutic process �

The division on the quality of care and services sets out nurses’ duties and obligations related to information to be given to the client and consent to care, and to the therapeutic process.

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Division IV Relations with persons with whom the nurse interacts in the practice of the profession

Division V Relations with the Order

Division VI Determination and payment of fees

These three divisions of the Code deal with nurses’ relations with the OIIQ and with other individuals in the practice of the profession. Rules are also laid out regarding the determination and payment of fees charged by nurses in private practice.

Division VII Conditions and procedures for the exercise of the client’s rights of access and correction of information contained in records established in respect of him or her

Client’s access to his record �Correction of information in the client’s record �Release of documents to the client �

This division describes under what circumstances and how a client may exercise his right to see and correct information contained in any records established in respect of him, whether the nurse practises in the public or private sector.

Division VIII Conditions, obligations and prohibitions relating to advertising

Division IX Professions, trades, industries, businesses, offices or duties incompatible with the dignity or practice of the profession

Division X graphic symbol of the Order

Divisions VIII and X describe rules relating to advertising aimed at the public and the use of the graphic symbol of the OIIQ. Division IX identifies exceptional cases in which a nurse may sell products or vaccines.

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ReadingAt this point, we suggest that you read the divisions of the Code of Ethics of Nurses (Appendix I), to familiarize yourself with its structure and to be able to identify the relevant sections of the Code in the following exercises.

ExErCisE 1.1

Identifying and applying sections of the Code of Ethics of Nurses

In this exercise you are asked to identify the relevant sections of the Code of Ethics of Nurses and apply them in each of the situations described. To check your answers and comments, see the answer guide on page 24.

Applying the sections of the Code to actual situations faced by Quebec nurses will help you understand how the ethical duties and obligations laid out in the Code are to guide you in your practice.

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Situation 1.1 1

The head nurse asks you to take part in training, during your working hours, on a new device that will be used in your unit. You wonder whether you are required to attend this training, which you consider an extra task.

What would you do? Would you attend the training or not?

What section(s) of Division I of the Code of Ethics can guide you in your decision?

Given your ethical duties and obligations, if this situation occurred in your practice, would you make the same decision? If not, please explain.

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Situation 1.1 2

You are working the night shift, and you haven’t been able to sleep for two days. One of your clients has a prescription for Ativan® as required. You wonder whether you can take an Ativan® tablet and mark it down with the client’s name.

What would you do? Take the client’s Ativan® or not?



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Situation 1.1 3

You are caring for an elderly client who has trouble communicating. Members of his family, who are constantly at his bedside, complain that his dressing hasn’t been changed yet. You are completely overwhelmed with work. You try unsuccessfully to explain the situation to the family, and you can feel your patience wearing thin. You wonder whether you should ask a colleague to intervene.

What would you do? Would you ask your colleague to intervene or not?

What section(s) of Division II of the Code of Ethics can guide you in your decision?


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Situation 1.1 4

You are new to the care unit. You have to administer a new and experimental drug, but you don’t know its side effects. You wonder whether you can administer it.

What would you do? Would you administer the drug or not?

What section(s) of Division III of the Code of Ethics can guide you in your decision?


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Situation 1.1 5

A nurse working in the same hospital as you is visiting her motherinlaw, who is on your unit. She asks to see the woman’s record so that she can better understand her condition. You wonder whether you can let her consult her motherinlaw’s record.

What would you do? Would you let her consult her motherinlaw’s record?

What section(s) of Division II of the Code of Ethics can guide you in your decision?


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Situation 1.1 6

You are a nurse specializing in foot care and would like to publish an advertisement in your neighbourhood newspaper. You are looking for diabetic clients. You wonder whether you can state in your advertisement that your services are more personalized than those of other nurses, given your experience with this clientele.

What would you do? Would you include this statement in your advertisement or not?

What section(s) of Division VIII of the Code of Ethics can guide you in your decision?


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Situation 1.1 7

You are coming off the day shift, when your colleague working the night shift calls to tell you she will be about 20 minutes late. This inconveniences you, because you have to pick up your children at the daycare. The nursing assistant who is working the evening shift suggests that you leave, saying that she and the orderly will keep an eye on your section. You wonder whether you can leave, given the circumstances.

What would you do? Would you leave or not?

What section(s) of Division III of the Code of Ethics can guide you in your decision?


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Situation 1.1 8

You are scheduled to work the night shift. Although you had a few glasses of wine this evening, you feel in relatively good shape. You hesitate to report for work, but you can’t really afford the loss of pay if you don’t.

What would you do? Would you report for work or not?



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Situation 1.1 9

You are a nurse in private practice. A client you care for in his home would like you to sell him dressings, because he cannot get out to buy them himself. You wonder whether you are allowed to do so.

What would you do? Would you sell him the dressings or not?

What section(s) of Division IX of the Code of Ethics can guide you in your decision?


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Situation 1.110You are looking for a way to improve your chances of getting a position you have applied for in the motherchild unit. You have 10 months’ experience in this field. When filling out the application, you hesitate between checking off “less than one year’s experience” or “1 to 3 years’ experience.”

What would you do? Would you check off “less than one year’s experience” or “1 to 3 years’ experience”?

What section(s) of Divisions I and IV of the Code of Ethics can guide you in your decision?


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ExErCisE 1.1

Situation 1.1 1Decision: Attend the training.

Section: 18.Anurse shallkeepherorhisprofessionalknowledgeandskillsuptodateinordertoprovidecareandtreatmentinaccordancewithgenerallyacceptedstandardsofpractice.

Explanation: Professional competence means the knowledge, skills, attitudes and judgment a nurse needs to practise her profession, and the ability to apply them in a given clinical situation. Section 18 deals with the ethical obligation to keep her professional knowledge and skills up to date throughout her career, so that she can provide care and treatment in accordance with generally accepted standards of practice. In fact, maintaining professional competence is an ongoing process and each nurse’s individual responsibility. To meet this obligation, she may read relevant articles, consult databanks of evidence, attend conferences and conventions or take training offered by an institution, particularly when it is introducing new technology.

If the training offered by an employer is necessary for a nurse to be able to perform her professional duties, she is required to attend so as to acquire the knowledge and skills she needs to act competently.

Additional reading: Ethics Update

“Professional competence, an ethical obligation,” � The Journal, Vol. 2, No. 4, March/April 2005.

Situation 1.1 2Decision: Do not take the client’s Ativan®.

Sections: 13. A nurse shall not appropriate medications or other substances,including drugs, narcotic or anesthetic preparations or any otherpropertybelongingtoapersonwithwhomsheorheinteractsinthepracticeoftheprofession.

answer guide

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14. Anurseshallnot,inrespectofaclient’srecordoranyreport,file,researchrecordordocumentrelatedtotheprofession:[…](3)enterthereinanyfalseinformation;[…]

Explanation: Taking the client’s Ativan® would be the same as appropriating, i.e. stealing, medications belonging to her employer.

In addition, entering false information in the client’s record indicating that he received a dose of Ativan® could interfere with the continuity of care. If the client needed Ativan®, another nurse could refuse to give it to him, thinking that he had already received the prescribed dose.


“Falsifying, fabricating ... and the � Code of Ethics,” The Journal, Vol. 1, No. 3, January/February 2004.“Nurses and substance abuse problems: ethical responsibilities,” �

The Journal, Vol. 4, No. 1, September/October 2006.

Situation 1.1 3Decision: Ask your colleague to intervene.

Section: 29.Anurseshallactrespectfullytowardtheclientandtheclient’sspouse,familyandsignificantothers.

Explanation: It is a nurse’s responsibility to establish and maintain a professional relationship based on trust and respect for the client and his family.

When a nurse feels that she is about to lose patience, for any reason, she should ask a colleague for help. If she snaps at a client or shows signs of impatience, she could jeopardize her professional relationship with the person or have her professional conduct criticized if the client later files a complaint. A nurse should withdraw or ask for help if she feels she is about to react in a way she will later regret.

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“Obstacles in therapeutic relationships,” � The Journal, Vol. 8, No. 4, March/April 2001.“Remain calm in the midst of turmoil,” � The Journal, Vol. 8, No. 5, May/June 2001.

Situation 1.1 4Decision: Do not administer the medication before obtaining the necessary

information, in particular its side effects.

Section: 45.A nurse shall not be negligent when administering medication.In particular, when administering medication, a nurse shall havesufficientknowledgeofthemedicationandabidebytheprinciplesandmethodsapplicabletoitsadministration.

Explanation: A lack of knowledge regarding the new experimental drug could lead to inappropriate monitoring of the patient. To safely administer a drug, a nurse must know its class, its mechanism of action, the main therapeutic reactions and side effects, administration conditions, normal doses, contraindications and interactions with other medications.

A nurse who administers medication without sufficient knowledge cannot claim to be acting prudently. She must never act without thinking, and must take all necessary precautions. Negligence can have serious consequences for the client, and even lead to death.


“Administering medication: reminder of ethical obligations,” �

The Journal, Vol. 2, No. 2, November/December 2004.

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Situation 1.1 5Decision: Do not allow the nurse to consult her motherinlaw’s record.

Section: 31.AnurseshallabidebytherulessetforthintheProfessionalCodeinregardtotheobligationtopreservethesecrecyofconfidentialinfor-mationthatbecomesknowntoherorhiminthepracticeofherorhisprofessionandthecaseswheresheorhemaybereleasedfromtheobligationofsecrecy.

Explanation: The obligation to respect the confidentiality of information is fundamental to the very principle of respect for a person’s right to privacy and independence. It reinforces the concept of respect for others, who are entitled to have and keep secrets regarding information concerning themselves and to share them with whomever they wish.

The information in the client’s record is confidential, and the client has not waived her right to the secrecy of confidential information. Her nurse is obliged to take the steps necessary to preserve the confidential nature of information on her client.

The fact that a nurse works in a hospital does not give her the right to consult all clients’ records. She may consult only the records of clients under her care. To consult her motherinlaw’s record, the other nurse would first have to obtain the client’s consent.


“Disclosure of confidential information. Amendments to the � Code of Ethics of Nurses,” The Journal, Vol. 3, No. 1, September/October 2005.

Situation 1.1 6Decision: Do not include this statement.

Section: 71. Inherorhisadvertising,anursemaynotcomparethequalityofherorhisserviceswiththequalityoftheservicesprovidedorthatmaybeprovidedbyothernurses,andmaynotdiscreditordenigratesuchservices.

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Explanation: Nurses in private practice may use advertising to promote their services. They may mention their expertise, but they may not compare their services with those offered by other nurses, or discredit or denigrate other nurses’ services.


“Looking for clients? How to juggle employment and private practice �

while keeping your professional distance,” The Journal, Vol. 6, No. 5, May/June 1999.

Situation 1.1 7Decision: Do not leave without ensuring that the clinical monitoring required by

clients’ condition will be provided.

Sections: 43.A nurse who is providing care and treatment to a client may notabandonhimorherwithoutaseriousreason.

44.Anurseshallnotbenegligentinthecareandtreatmentprovidedtotheclientortotheresearchsubject.Inparticular,anurseshall:[…](3)take reasonable measures to ensure continuity of care andtreatment.

Explanation: A nurse is responsible for providing safe, quality care for the clients assigned to her. Before finishing her shift, she must be sure that the care required by her clients’ state of health will continue to be provided.

Relying on the nursing assistant and orderly as a temporary solution to her problem is not an acceptable way to ensure clients’ safety. They do not have the competence required to maintain the continuity of care in the absence of the nurse.

The solution would be to have another nurse take over. Remember that a nurse may not abandon her clients without a serious reason.

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“Making enlightened decisions about overtime,” � The Journal, Vol. 2, No. 1, September/October 2004.

Situation 1.1 8Decision: Do not report for work.

Section: 16.Inadditiontothecircumstancescontemplatedbysection54oftheProfessionalCode(R.S.Q.,c.C-26),anurseshallrefrainfrompractisingherorhisprofessionwhensheorheisinastatethatisliabletoimpairthequalityofcareandservices.

Inparticular,anurseisinastatethatisliabletoimpairthequalityofcareandservices ifsheorhe isundertheinfluenceofalcoholicbeverages,drugs,hallucinogens,narcoticoranestheticpreparationsoranyothersubstancewhichmaycauseintoxication,adiminutionordisruptionofthefacultiesorunconsciousness.

Explanation: Nurses must refrain from practising when they are in a state liable to impair the quality of care and services. The Disciplinary Council considers practising the profession with faculties impaired by drugs, alcohol or any other substance one of the most serious offences from a professional point of view, given the high risk of harm to clients. The complexity of care, the nature of decisions to be made and the often highrisk actions nurses are called on to take require constant vigilance, and also that a nurse must be in complete possession of her faculties and be able to exercise proper judgment at all times. Clients are entitled to receive safe care and to expect the nurse caring for them to be in a fit condition to practise her profession.


“Nurses and substance abuse problems: ethical responsibilities,” �

The Journal, Vol. 4, No. 1, September/October 2006.

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Situation 1.1 9Decision: Sell him the dressings and tell him what profit you are making, if any.

Section: 78.Anursemaynotsell,engageorparticipateforprofitinanydistri-butionofmedications,equipmentorproductsrelatedtoherorhisprofessionalactivities,exceptinthefollowingcases:

(1) whereasaleofproductsorequipmentismadeinresponsetoanimmediateneedoftheclientandisrequiredforthecareandtreat-menttobeprovided.Insuchcase,theclientshallbenotifiedofanyprofitrealizedbythenurseuponthesale;[…]

Explanation: When a client is unable to obtain a product, a nurse may sell it to him to simplify his life. If the nurse makes a profit on the sale, she must tell the client so that he can make an informed decision.


“Think before making the sale!,” � The Journal, Vol. 7, No. 3, January/February 2000.

Situation 1.110Decision: Check off “less than one year’s experience.”

Sections: 10. Anurseshallfulfillherorhisprofessionaldutieswithintegrity.

14. Anurseshallnot, inrespectofaclient’s recordoranyreport, file,researchrecordordocumentrelatedtotheprofession:[…](3)enterthereinanyfalseinformation;[…]

47.Anurseshallnotintentionallymislead,betraythegoodfaithoforengage in unfair practices toward a person with whom she or heinteractsinthepracticeoftheprofession.

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Explanation: Integrity is a professional value that not only must be reflected in professional relations with clients, but must also be at the basis of the nurse’s relations with the people with whom she interacts in her practice. Integrity, after all, is considered by lawmakers to be the very foundation of ethical duty.

In addition, checking off “1 to 3 years’ experience” would be considered entering false information in a document related to the profession.

Lastly, lying about one’s experience in order to obtain a position is an unfair practice and is forbidden as it could jeopardize clients’ safety or mislead them.


“Falsifying, fabricating... and the � Code of Ethics,” The Journal, Vol. 1, No. 3, January/February 2004.“Honesty and fairness in nurses’ relations with others in the practice �

of the profession,” The Journal, Vol. 4, No. 3, January/February 2007.

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EXERCISE 1.2

Determining the appropriate professional conduct in situations involving issues related to the Code of Ethics

This is a problem-solving exercise. The three situations described below require you to think about the appropriate professional conduct in situations affecting the quality of care and services.

To complete the exercise, we suggest that you:read the description of the situation carefully;1. do the suggested readings, so that you can determine the best approach;2. examine the problem using the 3. Code of Ethics worksheet.

Use the Code of Ethics worksheet presented below to document your problem-solving approach and break it down into three steps. This will let you identify the ethical issue and consult the Code of Ethics of Nurses to determine the appropriate professional conduct.

Once you have decided a strategy, you can check your answer by referring to the annotated worksheets in the answer guide on page 40.

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Identify the problemDetermine the significant clues in the situation and identify the nature of the problem.

1 Significant clues Obvious or probable signs that there is a problem.

Behaviours, reactions, context and circum-stances of the situation that make it possible for a problem to arise.

2 Ethical issueThe ethical problem to be avoided or resolved.

Consult the Code of Ethics of NursesIdentify and apply the appropriate sections of the Code of Ethics of Nurses.

Decide on a strategyDetermine the actions to be taken to avoid or resolve the problem.

These actions and behaviours sum up the appro-priate conduct.

This conduct must be consistent with the ethical duties and obligations of Quebec nurses.

Code of Ethics worksheet

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Situation 1.2 1

Lucy is a research nurse at a university hospital centre. She is collaborating on a study of a drug treatment targeting leukemia. The protocol has been approved by the centre’s research ethics committee.

Her responsibilities include recruiting research subjects and obtaining their consent. She then fills out a questionnaire on their state of health, takes blood samples and gives them the relevant information on the drugs they will be taking.

A few months after the study begins, she is instructed by the principal inves-tigator to recall ten subjects for bone marrow analyses. Since these analyses were not included in the research protocol, Lucy wonders whether she needs to obtain the clients’ consent again.

She mentions this concern to the principal investigator, who tells her that he needs this new data at this precise point in the drug therapy. The changes to the protocol have been submitted to the ethics committee, but it will be too late if they wait for the committee’s approval and the data will be lost.

The researcher asks Lucy to notify the ten subjects and set up appointments for the blood samples, pending the committee’s official approval. He says that in his opinion, the changes to the protocol will be accepted before the blood samples are taken. He explains that he wants to present his research findings at a conference to be held shortly.

Lucy checks the consent form signed by the subjects and sees that only blood samples are mentioned.

What would be the appropriate professional conduct for Lucy in this situation? Use the worksheet on the next page to work out your answer.

Additional reading

Ethics Update

“Nurses’ ethical obligations and patients’ consent to care,” The Journal, Vol. 2, No. 3, January/February 2005.

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Identify the problem1 Significant clues

Consult the Code of Ethics of Nurses

2 Ethical issue

Decide on a strategy

Situation 1.2 1Code of Ethics worksheet

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Situation 1.2 2

Chantal is a nurse in the emergency ward. It has been very busy this evening and the staff members are overwhelmed. She is starting to feel tired and finding it increasingly difficult to concentrate.

One of her clients, a 72-year-old woman, is under observation for abdominal pain. Mrs. Dorismon is very anxious, gesticulating wildly and walking up and down the corridor, although she has been instructed to stay in her bed. Her family asks the nurse to immediately administer medication to ease her discomfort. Chantal sees that her client has a prescription for Dilaudid®, and gives her some.

Five hours later, Mrs. Dorismon is again in pain. As she is preparing the analgesic, Chantal realizes that she gave her client a double dose the first time.

Could she have been distracted? Since the double dose had no consequences for her client, Chantal wonders whether she should consider this a medication error. The client is doing well. Does the attending physician have to be told?

What would be the appropriate professional conduct for Chantal in this situation? Use the worksheet on the next page to work out your answer.

Additional reading

Ordre des infirmières et infirmiers du Québec ( 2009). Surveillance clinique des clients qui reçoivent des médicaments ayant un effet dépressif sur le système nerveux central - Avis, 2e éd., Montreal, OIIQ.

Ethics Update

“Incidents and accidents now reported,” The Journal, Vol. 1, No. 1, September/October 2003.“Administering medication: Reminder of ethical obligations,” The Journal, Vol. 2, No. 2, November/December 2004.

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Situation 1.2 3

Annie is a nurse at a CLSC. She has been providing home care for the past six years, and is coming back from a one-year maternity leave.

She receives a call from Mrs. Lajoie, who is taking care of her husband at home. For two weeks now, he has been receiving care from the CLSC for wounds on his right foot. She explains to Annie that her husband is finding it difficult to adapt to the intermittent mode of the drainage device, particularly at night. She also tells her that the exudate has been pinker for two days. Mrs. Lajoie tells Annie that her colleague had suggested that she set the device to continuous mode if her husband became uncomfortable. She asks Annie whether she should make this adjustment, or stop the treatment during the night.

Annie consults the current treatment plan and notes that the portable wound drainage device (VAC®) is supposed to be in intermittent mode. She has read an article on this subject, but never had any training on the use of the device. She knows that it is a negative-pressure device that avoids scarring in the case of complex wounds.

Wound care is an activity reserved for nurses and calls for more and more specific knowledge these days; Annie is not familiar with this new technology.

What would be the appropriate professional conduct for Annie in this situation? Use the worksheet on the next page to work out your answer.

Additional reading

Ethics Update

“Professional competence, an ethical obligation,” The Journal, Vol. 2, No. 4, March/April 2005.

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EXERCISE 1.2


The nurse is collaborating on a research project approved by the research ethics committee.

Taking bone marrow samples is not included in the protocol.

The amendments to the protocol requested by the principal investigator for these samples have not yet been approved by the research ethics committee.

2 Ethical issueCan the nurse now call the research subjects to come in and give bone marrow samples?


Relevant section: 41.1 (2)According to section 41.1 (2) of the Code, free and informed consent must be obtained when there is any significant change in the research protocol.


The nurse must wait until the amended research protocol has been approved by the research ethics committee and obtain new consent from subjects before calling them in to take bone marrow samples.

Situation 1.2 1Annotated worksheetanswer guide

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Chantal realizes that she has administered a double dose of Dilaudid®.

The administration of this double dose had no consequences for the client.

2 Ethical issueMust Chantal report this medication error, even though there were no consequences?


Relevant section: 12According to section 12 of the Code, a nurse must report any incident or accident that results from her intervention or omission. This means that she must report it officially, for example by informing the head nurse or the physician, by entering a note in the client’s records or by completing an incident-accident report. The section also states that the nurse must not try to cover up the inci-dent or accident and must immediately take steps to correct the situation or to limit or remedy its consequences. Public protection demands that the error be reported immediately. To err is human, but covering up is deliberate and it could deprive the client of the care required to deal with the resulting consequences.


Chantal must report the accident, by informing the physician and completing a hospital incident- accident report.

Situation 1.2 2Annotated worksheet

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Annie is not very familiar with this new techno-logy.

She has read an article on the subject, but has never had any training on using the device.

2 Ethical issueCan Annie change the treatment plan for Mr. Lajoie’s wound?


Relevant sections: 17 and 18According to section 17 of the Code, a nurse must act competently. In particular, she must take into consideration the limits of her knowl-edge and skills. This means that a nurse must refuse to do an activity if she lacks the required competence or if she recognizes her limits in a given situation.

As stated in section 18 of the Code, professional competence means the knowledge, skills, atti-tudes and judgment a nurse needs to practise her profession, and the ability to apply them in a given clinical situation. Maintaining profes-sional competence is an ongoing process and each nurse’s individual responsibility.


Annie cannot change the treatment plan for Mr. Lajoie’s wound, given her current knowl-edge. She must consult a colleague or a wound care nurse.

Afterwards, she could ask her employer to give her training on the VAC® device.


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the professional relationshipThe second part of our examination of the Code of Ethics of Nurses deals with the professional relationship between a nurse and her client.

FundamentalsTo be able to respect the ethical duties and obligations inherent in the nurse/client relationship, you must understand the nature of the professional rela-tionship and its underlying principles and recognize its boundaries.

Nature of the professional relationship

Several sections of the Code of Ethics of Nurses deal with the relationship between nurses and their clients, in particular the relationship of trust to be established, the steps to be taken to preserve the secrecy of confidential infor-mation and prohibited professional behaviour.

There are three basic elements underlying the professional relationship between a nurse and her client:

Trust � : When a person consults a nurse for a health problem, he has no control over what happens to him. He is often insecure, and this makes him feel somewhat vulnerable. He is automatically drawn to place his trust in the nurse and expects that she will not abuse it. He relies on a health profes-sional with special knowledge and skills that he lacks and that he needs to solve his health problem.

Power � : Although the nurse is certainly on the client’s side, there is always an imbalance of power between the two. A nurse has access to privileged information on her client. She is the one with the expertise, and this situa-tion gives her authority and influence.

Intimacy � : The very nature of nursing creates physical, emotional and psycho-logical intimacy. However, the relationship between a nurse and her client is unequal, because he must agree to answer personal questions and agree to have her touch him, sometimes in private places. In her practice, a nurse must show excellent communication skills and great compassion.

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A professional relationship differs from a social relationship in various ways (see the table on the following page). Aside from the elements already men-tioned, it is also distinguished by the structured framework in which it occurs, by the fact that it is limited to the care setting and lastly, by the fact that a nurse is paid to provide care for the client.

A professional relationship encompasses the therapeutic relationship, which is limited to the period of care – ending when the client is discharged – whereas a professional relationship can extend beyond the time of discharge.

All these elements give a nurse power that she must not abuse. The relationship with the client must instead be established with a view to creating a partner-ship between the two, characterized by mutual respect and the achievement of a common goal.

It is up to the nurse to establish the boundaries of this relationship.

Boundaries of the professional relationship

Recognizing the boundaries of this relationship calls for great professional judgment on a nurse’s part, for there are grey areas where things are not always clear. A nurse must remain vigilant, so as not to step outside the bounds of her professional relationship. If she cares for clients at home or over a long period, she is particularly exposed to the risk of becoming involved in the private lives of the client and those around him.

A nurse must not share confidences with her client, unless it meets a thera-peutic need. For instance, a nurse could talk about her personal experience as the mother of a Down syndrome child to a client in the same situation, to help her overcome her troubles. This type of intervention, common in the thera-peutic relationship, must always be for the purpose of the client’s well-being and not the nurse’s personal interest.

It must be remembered that the therapeutic relationship ends when the client is discharged. The professional relationship, however, may extend over a longer period. It is not possible to set a precise deadline, for a nurse deals with many clients in different situations. She must be able to examine all aspects of the situation and be cautious when making a professional judgment concerning the length of the relationship.

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Characteristics Professional relationship (nurse-client)

Social relationship (i.e. friendship, romance)

Purpose of the relationship

To provide the client with care. The relationship is structured.

To satisfy a need for affection or show interest in someone. The relationship is spontaneous, not structured.

Location of the relationship

The location is defined and limited to the nursing care setting.

The location is often undefined and no restrictions apply.

Balance of authority

The relationship is unevenly balanced, since the nurse exercises power owing to her expertise, knowledge, influence and access to privileged information on the client.

The relationship is relatively balanced.

Responsibility for the relationship

The nurse, and not the client, is respon-sible for establishing and maintaining a professional relationship.

Both parties share responsibility for establishing and maintaining the relationship.

Requirements of the relationship

The professional relationship requires special knowledge, skills and aptitudes.

No specific requirements.

Remuneration The nurse is remunerated for the care provided to the client.

No remuneration.

Time devoted to the relationship

The time devoted to the relationship depends on the employment setting and organization of care.

Personal decision.

Length of the relationship

The professional relationship encompasses the therapeutic relation-ship, which ends when the client is discharged. The professional relation-ship may extend beyond this period, depending on the client’s vulnerability, health problems, length of the period of care and the likelihood of having to care for the client again.

The relationship may last a lifetime.

Source: Professional Boundaries for Registered Nurses: Guidelines for the Nurse-Client Relationship, © Alberta Association of Registered Nurses, 1998 (adaptation, OIIQ)

Characteristics of the professional relationship and the social relationship

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Section 38 of the Code of Ethics describes the main criteria to be taken into account when establishing the length of the professional relationship:

[…]“For the purpose of determining the duration of the professional relationship, the nurse shall take into consideration, in particular, the client’s vulnerability, the nature of the client’s health problem, the duration of the course of treatment and the likelihood of the nurse having to provide care to the client again.”

The client’s vulnerability may stem from a variety of factors, including�

his personal situation (divorce, recent bereavement, support network);�

worries about his health problem. �

The health problem may be physical or mental, acute or chronic.�

The duration of the course of treatment may vary from a few hours to �

a few weeks, months or years.

The nurse may have to provide care to the client again because of �

frequent hospitalizations or follow-up as an outpatient or in the home.

The nurse is responsible for setting the boundaries of the professional relation-ship. She must first assess the situation as objectively as possible, including her own behaviour toward the client. It is recommended that she speak to a colleague or her immediate superior, for instance, as soon as she has any doubts.

After assessing the situation, the nurse may realize that she is in danger of crossing the boundaries of the professional relationship. She must then decide on the best way of avoiding this, while focusing on the client’s well-being and safety. If she has to end the therapeutic relationship, she must tell the client and ensure that she is replaced by a competent person. The transition must be carried out with respect for the client.

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ReadingThis is a good time to read the articles on the professional relationship published in the “Ethics Update” column of the OIIQ Journal, to prepare for the next two exercises.

“Knowing the basic principles of a professional relationship - Part � 1,” The Journal, Vol. 7, No. 4, March/April 2000.“The professional relationship, a special balance – Part � 2,” The Journal, Vol. 7, No. 5, May/June 2000.“Respecting the boundaries of a professional relationship – Part � 3,” The Journal, Vol. 8, No. 1, September/October 2000.“Reacting in time to safeguard the boundaries of a professional �

relationship – Fourth and final part,” The Journal, Vol. 8, No. 2, November/December 2000.“The professional relationship: How long does it last?”, � The Journal, Vol. 1, No. 4, March/April 2004.

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EXERCISE 1.3

Determining the nature and boundaries of the professional relationship

In this exercise you are asked to determine the nature and boundaries of the professional relationship in three real-life situations.

To check your answers, consult the answer guide on page 51.

Situation 1.3 1

Sophie is a nurse in a rehabilitation centre, where she is caring for a young man who has become quadriplegic as a result of a skiing accident. Charles is very nice and reminds her of one of her sons who is also a competitive skier. Charles has been hospitalized for four months.

Sophie notices that she often asks her colleagues to switch assignments with her so that she can take care of Charles. She feels that her care is more personal-ized. The young man has also told her that his days go by faster when she is at his bedside, which makes her feel very good. She often dreams of giving him a surprise by inviting him out to the ski hill at Christmas and taking him down the hill in a sled adapted for disabled users.

May Sophie take Charles out skiing? Explain.

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Situation 1.3 2

Pierre, a nurse in the hemodialysis unit, cared for Martine, a young client with chronic renal impairment, for two years. He very much enjoyed looking after her when she came to the hospital every week. Now she is receiving home dialysis services under the supervision of a nurse clinician. Martine invites Pierre to visit her at home on his days off.

May Pierre accept Martine’s invitation? Explain.

Situation 1.3 3

Josée is a nurse in the orthopedic unit. She is caring for Mr. Wilson, who had an operation to repair a fractured femur. She notices that he asks her several questions about her private life. She gives him evasive answers, but senses that he is interested in her. He leaves the hospital after three days.

Mr. Wilson lives in Josée’s neighbourhood, and the two of them meet by chance at a street party two months later. He says he would like to see her again to get to know her better and perhaps to establish an intimate relationship.

May Josée accept his invitation? Explain.

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EXERCISE 1.3

Situation 1.3 1Decision: Sophie may not take Charles skiing.

Explanation: The nurse in this situation has struck up a friendship with Charles and perhaps even sees him as a sort of son. This relationship exceeds the boundaries of simply providing care, and satisfies the nurse’s own needs. She would like to make him happy by organizing a special ski outing, but this initiative is not part of her duties and is not part of the care she is responsible for giving him.

Since the therapeutic relationship for rehabilitation lasts a long time, respecting boundaries is especially difficult. Given the clues showing Sophie that she is in danger of stepping outside these boundaries, she should discuss the situation with the head nurse or a colleague, to ensure that she maintains her profes-sional relationship with the client.

Situation 1.3 2Decision: Pierre may not accept Martine’s invitation.

Explanation: Although the therapeutic relationship is over, their professional relationship is not. For one thing, Pierre took care of Martine for two years. Secondly, she still requires follow-up – now provided by the nurse clinician, but Pierre might be required to care for her again. Consequently, if Pierre visited her at home, it would be to provide social support and friendship and to show his interest in the client, and these are not part of the clinical follow-up.

Situation 1.3 3Decision: Josée may accept Mr. Wilson’s invitation.

Explanation: Since the period of care was short and the acute physical health problem required no follow-up by the nurse, Josée may consider that enough time has gone by for the professional relationship to be over.

answer guide

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EXERCISE 1.4

Determining the appropriate professional conduct in situations relating to the professional relationship

This is a problem-solving exercise. The two situations described below require you to think about the appropriate professional conduct so as to maintain the nurse/client relationship.

To complete the exercise, we suggest that you:read the description of the situation carefully;1. do the suggested readings, so that you can determine the best approach;2. examine the problem using the professional ethics worksheet. 3.

Use the professional ethics worksheet presented below to document your problem-solving approach and break it down into three steps. This will let you identify the professional ethics issue and consult the Code of Ethics of Nursesto determine the appropriate professional conduct.

Once you have decided on a strategy, you can check your answer by referring to the annotated worksheets in the answer guide on page 58.

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1 Significant cluesObvious or probable signs that there is a problem.

Behaviours, reactions, context and circums-tances of the situation that make it possible for a problem to arise.

2 Ethical issueThe professional ethics problem to be avoided or resolved.



These actions and behaviours sum up the appro-priate conduct.



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Situation 1.4 1

Beatrice has been a psychiatric nurse for 15 years. She has taken various training courses to keep her knowledge of psychiatric care up to date. In team meetings, her colleagues appreciate her competence. She has been caring for Frederick, a 36-year-old man, for a month now. He was admitted for severe depression and a suicide attempt, his first, after a bitter divorce.

Frederick is to be discharged at the end of the week. As Beatrice is planning his discharge with him, he takes the opportunity to tell her that she has been an important part of his therapy, and how much he has appreciated her compe-tence and empathy. He says he would like to see her again, on a personal basis. Beatrice had already sensed on a number of occasions that Frederick was attracted to her. She had enjoyed talking about his divorce with him, since she was also going through a separation, and had shared her personal experiences with him as a way of helping him.

She knows that other colleagues will be dealing with Frederick’s case on an out-patient basis over the coming year. The therapeutic nurse/client relationship had developed to her satisfaction. Now that their professional relationship has suddenly taken this delicate turn, Beatrice wonders how to give him an answer that will not hurt him. She knows that Frederick is very sensitive to rejection – they have worked with him at length on this topic during his stay.

What would be the appropriate professional conduct for Beatrice in this situation?

Additional reading

Ethics Update

“Knowing the basic principles of a professional relationship - Part � 1,” The Journal, Vol. 7, No. 4, March/April 2000.“The professional relationship, a special balance – Part � 2,” The Journal, Vol. 7, No. 5, May/June 2000.“Respecting the boundaries of a professional relationship – Part � 3,” The Journal, Vol. 8, No. 1, September/October 2000.“Reacting in time to safeguard the boundaries of a professional �

relationship – Fourth and final part,” The Journal, Vol. 8, No. 2, November/December 2000.“The professional relationship: How long does it last?”, � The Journal, Vol. 1, No. 4, March/April 2004.

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Situation 1.4 2

Isabella, a 38-year-old woman, is hospitalized in the gynecology unit for surgery. She has two boys, 8 and 10 years old, from her first marriage. After looking into her case, the attending physician tells her that it would be best for her to have a hysterectomy. Isabella remarried two years ago. Her husband, Gregorio, has stayed close to her during her hospitalization and is asking many questions about his wife’s condition. The nursing staff has noticed that he seems quite anxious.

When she is about to sign the consent form for the operation, Isabella asks to speak privately with Julie, her nurse. She is crying and tells the nurse that her husband is determined to have children. She is worried about his reaction to the hysterectomy, and has decided not to tell him right away what surgery she is scheduled for on the next day. She asks Julie not to say anything to him about her hysterectomy for the moment.

On the day of the operation, Gregorio comes to the nursing station and asks to speak to Julie. He is worried at seeing Isabella so pale, and wants to know about the surgery. The nurse tells him that his wife returned from the operating room only one hour ago, and that her post-operatory condition is normal. He asks, in an anxious tone, what kind of operation she had, and says he has the right to know. The nurse tells him that Isabella will explain what type of surgery she had, when she is able. Gregorio insists.

What would be the appropriate professional conduct for Julie in this situation?

Additional reading

Ethics Update

“Remain calm in the midst of turmoil,” � The Journal, Vol. 8, No. 5, May/June 2001.“Respect in the relationship between nurses and clients,” � The Journal, Vol. 2, No. 5, May/June 2005.“Disclosure of confidential information. Amendments to the � Code of Ethics of Nurses,” The Journal, Vol. 3, No. 1, September/October 2005.

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EXERCISE 1.4


The nurse has been caring for a client admitted for a severe depression and suicide attempt, for the past month. He says he would like to see her again, on a personal basis. She knows that the client will be receiving follow-up treatment as an outpatient.

She has enjoyed talking with him about his divorce, since she is in the same situation. She shared her personal experiences with her client to help him cope.

2 Ethical issueHow can the nurse maintain their professional relationship?


Relevant section: 38According to section 38 of the Code, a nurse may not establish a personal friendship or an intimate, amorous or sexual relationship with a client for the duration of the professional rela-tionship. She must be attentive to the dynamic developing in her relations with clients.

A nurse must be able to recognize signs that she is at risk of exceeding the boundaries of the professional relationship. She is the one who must establish these boundaries.


In this situation, Beatrice must tell Frederick that, as a nurse, she cannot enter into any other kind of relationship with him.

She must remember that the professional rela-tionship may continue long after the therapeutic relationship, given the client’s health problems and risks of recurrence.

If she had any doubts about the risks of exceeding the boundaries of the professional relationship, her strategy would then be to discuss the matter with her colleagues, a superior or a person able to advise her on professional ethics issues.


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Isabella confides to the nurse that she is worried about her husband’s reaction and has decided not to tell him right away that she is going to have a hysterectomy.

On the day of the operation, her husband insists on knowing what operation Isabella has had.

2 Ethical issueIs the nurse allowed to disclose to Gregorio the type of surgery his wife has had?


Relevant section: 31According to section 31 of the Code, a nurse must abide by the rules concerning the obligation to preserve the secrecy of confidential information that becomes known to her in the practice of the profession, unless the client has authorized her to disclose this information.


To preserve the secrecy of the confidential infor-mation, Julie may not tell Gregorio what type of surgery his wife had. She may offer to help Isabella discuss the surgery with Gregorio, if Isabella wishes.


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professional independence and conflicts of interestThe third part of our examination of the Code of Ethics of Nurses deals with the nurse’s professional independence and conflicts of interest.

Fundamentals

Professional independence

A nurse must show professional independence in the course of her professional activities, i.e. practise her profession with objectivity and disregard any inter-vention by a third party that could affect the performance of her professional duties to the detriment of the client.

The following exercise will help you determine whether you have properly understood the concept of professional independence.

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ExErCisE 1.5

Recognizing the elements of professional independence

In this exercise you are asked to recognize and note the elements of profes-sional independence in each of the two situations described below. Then you can check your answer by referring to the annotated worksheets in the answer guide on page 64.

Situation 1.5 1

A foot-care nurse is asked to provide foot care twice a week for diabetic clients. While she is at the private medical clinic, she notices advertisements on the walls for different firms. She tells the owner that she does not promote the products of any specific company, but that she advises clients, if applicable, on the type of products required in their situation, and that they can buy them wherever they choose. She asks the owner of the clinic to note in her contract that she is free to use those products that she deems necessary for her clients.

What has the nurse done to safeguard her professional independence?

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Situation 1.5 2

A nurse has to assess the pain of a client who is beginning a new analgesic therapy. The client is known in the healthcare community and, the last time she was hospitalized, she filed a complaint about certain nurses, including the nurse who is to conduct this assessment.

How could this situation compromise the nurse’s professional independence?

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ExErCisE 1.5

Situation 1.5 1Answer: She is not agreeing to promote a specific product.

She chooses the products she uses based on their effectiveness and the client’s needs.

She clarifies the situation in writing, to make sure that she is not influenced in her practice by any obligation toward the clinic.

Situation 1.5 2Answer: The nurse might find it difficult to ignore the complaint filed against her.

If so, that could compromise her objectivity when assessing the client’s level of pain.

answer guide

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Fundamentals

Conflict of interest

All nurses may occasionally find themselves in a conflict of interest in their day-to-day practice. This situation occurs when the interests concerned are such that the nurse may be influenced to favour her own interests over those of her client or the nurse’s judgment and loyalty toward her client may be unfavourably affected. Such interests may be of a personal or other nature. The conflict may be real, apparent or potential.

A � real conflict is a situation in which a conflict has occurred or is occurring. For instance, a nurse who is responsible for assessing supplies in a hospital agrees to promote a specific company’s product in return for a paid vaca-tion trip.

An � apparent conflict is a situation that could reasonably be interpreted as a real conflict. An apparent conflict may exist whether or not there is a real conflict. For instance, a nurse who is an expert in caring for wounds always uses a given company’s products and encourages others to do likewise.

A � potential conflict is a situation in which there are interests involved that could come into conflict, although they have not as yet. For example, a nurse who is a member of a research ethics committee and has a stake in a given company that might at some point submit a research protocol for consideration.

Conflicts of interest observed in the nursing context most often involve money, information or influence.

Conflicts involving money � can occur both in the nurse/client relationship and in relations between nurses and the industry. They originate with anything that has monetary value and that compromises or appears to compromise the nurse’s professional decisions.

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A nurse places herself in a conflict of interest when she receives, in addition to the remuneration to which she is entitled, any rebate, commission or benefitrelated to her professional activities.

A rebate or commission is a refund, a price reduction or a share in the profits.

The term benefit refers to a profit, good, advantage, interest, gain or privilege. The expression “pecuniary benefit” refers to a gain, remuneration or reward. A material benefit is a tangible benefit or property. It may take various forms, ranging from a gift to a tip or bonus. A gift is something offered to someone to please her, such as a donation or a present.

Conflicts involving information� occur when a nurse uses privileged informa-tion obtained in the performance of her duties or confidential information contained in a client’s record, for example. A nurse is in a conflict of interest, for instance, if she takes advantage of her work at a healthcare establishment to appropriate a pregnant woman’s contact information so as to offer her a prenatal course as a self-employed worker.

Nurses are required by law (see section 2, on legal considerations) and the Code of Ethics of Nurses to safeguard the confidentiality of all information on their clients that they obtain in the performance of their duties.

Conflicts involving influence� occur when a nurse uses her influence to obtain a personal benefit or to benefit a third party, for instance a colleague in pri-vate practice or a member of her family. Nurses have some influence in the practice of their profession, in view of their competence and their expertise, as well as the information they possess.

This means that they can influence a decision by a client or a third party, such as a business, with a view to obtaining direct or indirect benefits for themselves or another party.

There is also a conflict of interest when a secondary benefit, such as financial gain, information and influence or personal prestige, can unduly influence a nurse’s judgment. In the performance of her professional duties, a nurse must display professional independence and avoid any conflict of interest.

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ReadingAt this point we suggest that you prepare for the following exercise by reading pages 1 to 11 of the Order’s publication, Pour des relations professionnelles intègres, Orientations à l’intention des infirmières concernant l’indépendance professionnelle et les conflits d’intérêts.

ExErCisE 1.6

Recognizing a conflict of interest

To efficiently deal with conflicts of interest, you must first realize that they exist, and then evaluate their repercussions and the interests involved. The key part of this approach is to determine whether the situation actually or apparently interferes with the independence required for the nurse’s profes-sional judgment.

We suggest that you use the acronym I-N-T-E-G-R-I-T-Y to help you recognize conflicts of interest. Remember that this moral value is viewed as the corner-stone of ethical duties. The meaning of this acronym and an example of its application in a clinical situation are presented below.

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How to recognize a conflict of interest

i Indication: What elements can indicate that you are in a conflict of interest?

n Nature: What is the nature of the conflict of interest?

t Type: What type of conflict of interest is this?

e Explanation: What exactly is the conflict of interest in this situation?

g Gain: What is the gain or benefit involved in the situation?

rRepercussions: What are the possible repercussions on your objectivity?

Could this benefit influence your current or future decisions relating to the client or project?

Would you feel obliged to someone now or in the future, in return for this benefit?

iInterference: Do these repercussions compromise or apparently compromise

the independence necessary for your professional judgment?

Can these repercussions compromise your relationship of trust with your clients?

t Transparency: Would you be uncomfortable if your colleagues, employer or clients learned of your behaviour in this situation?

y You avoid the conflict: What preventive steps can you take, as spelled out in the Code of Ethics of Nurses, to avoid the conflict?

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Read the following example, and then study the situations described in the following pages, using the I- N-T-E-G-R-I-T-Y acronym. Check your answers by referring to the answer guide on page 74.

Exemple

You are a home care nurse. To thank you for your services, one of your clients regularly gives you prepared dishes that his wife sells in her business.

i Indication: You accept dishes as thanks for your services.

n Nature: This is a conflict of interest involving money.

t Type: It is a real conflict of interest.

e Explanation: Accepting a material benefit on top of your remuneration places you in a real conflict of interest involving money.

g Gain: You receive a benefit in the form of prepared dishes, representing a gift with monetary value.

r Repercussions: Accepting a gift from your client may make you feel obliged toward him.

iInterference: Feeling obliged toward your client could interfere with your

objectivity, and affect your professional judgment. The situa-tion could create expectations for the client, who might expect privileged attention.

tTransparency: You would feel uncomfortable if other clients learned of your

behaviour, since you would worry that they would also feel obliged to give you gifts.

y You avoid the conflict: Prevent the conflict of interest by telling your clients that you cannot accept gifts.

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Situation 1.6 1

You are a long-term care nurse. You talk about your financial situation with a client who was an accountant before contracting multiple sclerosis. He offers to look over your budget for free.

iIndication:

nNature:

tType:

eExplanation:

gGain:

rRepercussions:

iInterference:

tTransparency:

yYou avoid the conflict:

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Situation 1.6 2

You are a wound-care nurse. You always use products from the same company, because you are happy with them. Consequently, you recommend them to your clients when they come to the outpatient clinic.

iIndication:

nNature:

tType:

eExplanation:

gGain:

rRepercussions:

iInterference:

tTransparency:


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Situation 1.6 3

You are a home-care nurse and you make postpartum visits. You give the names of new teenage mothers to a colleague who is recruiting subjects for nursing research.

iIndication:

nNature:

tType:

eExplanation:

gGain:

rRepercussions:

iInterference:

tTransparency:


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Situation 1.6 4

You are a nurse in a diabetes clinic. You hand out blood glucose meters from various companies, free of charge, when you meet new diabetic clients. One of the companies gives you a bonus of $20 whenever you give one of its blood glucose meters to a new client.

iIndication:

nNature:

tType:

eExplanation:

gGain:

rRepercussions:

iInterference:

tTransparency:


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i Indication: Your client offers to look over your budget for free.


t Type: This is a potential conflict of interest.

e Explanation: Accepting a material benefit on top of your remuneration would place you in a real conflict of interest involving money.

g Gain: You would receive a benefit in the form of accounting services, representing a gift of monetary value.

r Repercussions: Accepting this service from your client could make you feel obliged toward him.

iInterference: Feeling obliged toward your client could interfere with your

objectivity, and affect your professional judgment. The situa-tion could create expectations for the client, who might expect privileged attention.

tTransparency: You would feel uncomfortable if other clients learned of your

behaviour, since some of them might worry that they would not receive such good care because they had not given you some token of their appreciation.

y You avoid the conflict: Refuse his offer and avoid indirectly soliciting favours from clients.

Situation 1.6 1

ExErCisE 1.6answer guide

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i Indication: You always use products from the same company and recom-mend them to your clients.

n Nature: This is a conflict of interest involving influence.

tType: This is an apparent conflict of interest, since always recom-

mending products from the same company could be interpreted as a potential source of a conflict of interest.

e Explanation: Recommending products from the same company all the time puts you in an apparent conflict of interest involving influence.

g Gain: No gain.

r Repercussions: Clients might think that your objectivity is affected.

i Interference: There is no interference, since there is no real or potential conflict.

tTransparency: You would feel uncomfortable if your clients thought you

were obliging them to use products only from the company in question.

yYou avoid the conflict: Objectively inform clients of all products they need given their

state of health, without promoting any particular product, and allow them to make informed decisions.

Situation 1.6 2

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i Indication: You give the names of new teenage mothers to a colleague who is recruiting research subjects.

n Nature: This is a conflict of interest involving information.

t Type: This is a real conflict of interest.

eExplanation: Using privileged information obtained in the performance of

your duties places you in a real conflict of interest involving information.

g Gain: You help a colleague recruit research subjects.

rRepercussions: By helping a colleague recruit research subjects, you are dis-

closing confidential information without the consent of these new mothers.

i Interference: Using confidential information without first obtaining clients’ consent interferes with the relationship of trust.

t Transparency: You would be uncomfortable if your clients learned that you had put your colleague’s personal interests ahead of theirs.

y You avoid the conflict: Do not use confidential information to obtain any direct or indirect benefits.

Situation 1.6 3

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i Indication: You receive a bonus whenever you give new clients a blood glucose meter from a certain company.


t Type: This is a real conflict of interest.

e Explanation: Accepting a bonus places you in a real conflict of interest involving money.

g Gain: You receive a benefit in the form of a bonus.

r Repercussions: Accepting a bonus from the blood glucose meter company would make you feel obliged toward it.

iInterference: Feeling obliged toward the company could interfere with your

objectivity in choosing blood glucose meters to hand out to new clients, and prevent you from telling them about the other meters available.

t Transparency: You would feel uncomfortable if your clients learned that you are receiving a bonus.

yYou avoid the conflict: Do not accept bonuses from companies and always act in your

clients’ best interests when you recommend materials they need, given their state of health.

Situation 1.6 4

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ExErCisE 1.7

Determining the appropriate professional conduct in situations where there is a risk of a conflict of interest

This is a problem-solving exercise. The situations described below require you to think about the appropriate professional conduct so as to ensure your professional independence as a nurse and avoid any conflict of interest.

To complete the exercise, we suggest that you:read the description of the situation carefully;1. do the suggested readings, so that you can determine the best approach;2. examine the problem using the 3. Code of Ethics worksheet.

Use the Code of Ethics worksheet presented below to document your problem-solving approach and break it down into three steps. This will let you identify the ethical issue and consult the Code of Ethics of Nurses to determine the appropriate professional conduct.

Once you have decided on a strategy, you can check your answer by referring to the annotated worksheets in the answer guide on page 86.

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1 Significant cluesObvious or probable signs that there is a problem.


2 Ethical issueThe ethical problem to be avoided or resolved.



These actions and behaviours sum up the appropriate conduct.



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Situation 1.7 1

Mary has been working as a nurse in an inner-city neighbourhood youth clinic for seven years. The clinic offers complete medical and psycho-social services for young people under age 18. It provides services adapted to their needs, including contraception, pregnancy and sexually transmitted diseases. Mary works as part of a multidisciplinary team.

The nurses on the team are assigned in turn to clinical services, where they deal with young visitors to the clinic or answer questions over the telephone. Mary is on duty today. The young people who turn to the drop-in clinic come with urgent problems, and are often in crisis.

Annie, a 16-year-old girl, comes to the clinic for a pregnancy test. The recep-tionist gives her a questionnaire to be filled out before she meets the nurse. When Annie hands in the questionnaire, she asks the receptionist whether the clinic offers abortion services. She is visibly upset, and has no one with her. The receptionist tells her that Mary, the nurse on duty, is waiting in her office for the assessment interview and will be happy to answer all Annie’s questions.

Mary is surprised to see that her client is her son’s new girlfriend. Annie is also surprised, and becomes even more anxious. She starts to cry and says she needs help, because she is pregnant. She came to the youth clinic because one of her girlfriends at school had been to the clinic before and told her they could help. Mary listens as the young girl pours her heart out.

What would be the appropriate professional conduct in this situation?

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2 Ethical issue



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Situation 1.7 2

Francine is a wound-care nurse at a university hospital centre. As a stoma-therapist she is up to date on the latest findings in the field of wound care. She also works on developing treatment plans for certain types of wounds in her work setting.

Different products from various companies are used in wound care. Sales repre sentatives often meet with specialists to promote their products and learn about new needs. This collaboration sometimes makes Francine uncom-fortable, although it is necessary for clients’ well-being and an accepted part of pharmaceutical sales.

The sales representative from the ZY Company would like to promote a new product, and asks Francine to give a sample of a barrier ointment to all new wound clients she treats.

At the same time he gives her a pass to a symposium to be held the following summer, at which a number of subjects of interest to Francine will be discussed.


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2 Ethical issue



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Situation 1.7 3

Denise is a long-term care nurse. She has been working at a residential centre for two years. Mrs. Marcado, a 70-year-old resident, was admitted to Denise’s unit after a severe stroke. She is hemiplegic on her right side and is aphasic. Despite spending time at a rehabilitation centre, she has not recovered enough autonomy to be able to return home.

Denise has been caring for Mrs. Marcado for six months. Her husband comes every day, from 1 to 8 p.m., and is very much involved in caring for his wife. Denise has come to know the couple well and sometimes drops in during her afternoon break to discuss Mrs. Marcado’s case with her husband. He has several times invited her to have a coffee with them. During one of these conversations, Denise mentions that her young daughter is a real snowboarding enthusiast, but that Denise cannot afford to share this pastime with her.

Mr. Marcado often tells Denise that he is very happy with the care his wife is receiving. He says, with a tear in his eye, that the centre feels like his second home.

A few days before Denise leaves on vacation, he discreetly hands her an envelope with a gift certificate for a ski centre in the Laurentians. He says it is a small token of thanks for the good care she has given his wife. Denise is confused, and very touched at his thoughtfulness.


Additional reading

Ethics Update

“Yes or no to gifts? Establishing limits in a professional relationship can �

save you some worries,” The Journal, Vol. 7, No. 2, November/December 1999.

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2 Ethical issue



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ExErCisE 1.7


Her son’s girlfriend comes to the drop-in clinic for a consultation regarding an unplanned pregnancy.

2 Ethical issueMay the nurse deal with Annie?


Relevant section: 21According to section 21 of the Code, a nurse must safeguard her professional independence at all times.

She must practise her profession with objec-tivity. Consequently, she must ensure that her professional judgment is not affected by family ties or friendships.


Deal with the immediate crisis facing the young client, within the constraints of a professional relationship.

Ask a colleague to take over the assessment interview and follow up with the client.

Tell the client that her confidentiality will be protected at all times.


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The sales representative asks the nurse to give a product sample to all new clients she treats.

He gives her a free pass to a symposium dealing with a number of subjects that interest the nurse.

2 Ethical issueMay the nurse give a product sample to new wound clients?

May she accept the pass to the symposium?


Relevant sections: 21, 23 (2) and (3)The nurse may distribute the samples to clients provided that the product meets their needs.

However, the nurse may not promote the product or benefit from it.


Francine should give a sample of the product to clients who need it, depending on her clinical assessment, but refuse the pass to the sym-posium. However, she could suggest to the representative that his company contribute an equivalent amount to the Council of Nurses or the Nursing Department, for instance, to sup-port nursing training.


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The nurse takes breaks with the client and her husband.

The nurse has confided in them about her finan-cial situation.

The client’s husband gives the nurse a gift certificate to express his appreciation.

2 Ethical issueMay the nurse accept the gift certificate?


Relevant sections: 21, 23 (2)Accepting a gift would place the nurse in a situation where she was potentially obliged to reciprocate. She could feel indebted to the client and do her a favour, which would inter-fere with her objectivity in deciding what care to give her.


Refuse the gift, since accepting it could create expectations that could undermine the profes-sional relationship and place the nurse in a conflict of interest.

She must remain vigilant in the professional relationship, especially over the long term, in particular by not confiding in the client or her husband regarding her personal problems or financial situation.


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for Quebec Nursesconsiderations

other legal

The second section of the self-study guide deals with other legal considerations for Quebec nurses. This part looks at the legal framework governing the practice of the profession, and then the client’s rights with respect to health care and the nurse’s professional liability.

Section 2


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Fundamentals

Legislative framework governing nursing in Quebec

Nurses in Quebec are considered professionals, meaning that they are obliged to display competence and integrity and have full ethical and civil liability. Quebec legislation imposes obligations that must guide nurses in their practice. To practice safely, nurses must know and understand their legal obligations so as to be able to exercise their judgment in such a way as to respect and protect their clients’ rights.

This section examines the relevant provisions of certain pieces of legislation:

Charter of Human Rights and Freedoms; �

Civil Code of Québec; �

Act respecting health services and social services; �

Act respecting the protection of persons whose mental state presents �a danger to themselves or to others;

Youth Protection Act; �

Act respecting Access to documents held by public bodies and the Protection �of personal information.

The Professional Code and the Nurses Act, which govern the professional system and the field of practice of nursing, respectively, will not be discussed here.

clients’ rights with respect to health care

A number of Quebec laws give clients rights that nurses must protect and respect. More specifically, these rights are laid out in the Charter of Human Rights and Freedoms, the Civil Code of Québec and the Act respecting health services and social services. It is important that nurses be familiar with the rele-vant provisions of these laws, so that they understand the resulting obligations.

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The Charter of Human Rights and Freedoms is the cornerstone of the legisla-tive system in Quebec. It gives everyone the rights and freedoms they need to develop their autonomy and make informed choices in accordance with their own interests.

These fundamental rights and freedoms include:

the right to life, and to personal security, inviolability and freedom (s. � 1);

the right to assistance (s. � 2);

freedom of conscience, freedom of religion, freedom of opinion, freedom of �expression, freedom of peaceful assembly and freedom of association (s. 3);

the safeguard of their dignity, honour and reputation (s. � 4);

respect for their private life (s. � 5);

non-disclosure of confidential information (s. � 9).

Section 10 of the Charter guarantees all individuals the right to full and equal recognition and exercise of their human rights and freedoms, without distinc-tion, exclusion or preference based on discrimination. The list of grounds for discrimination includes traditional ones such as ethnic origin, sex and reli-gion, but also more contemporary grounds such as social condition, political convictions, pregnancy and sexual orientation. Discrimination is prohibited in juridical acts and in employment, housing and access to public places and services. From a legal point of view, a nurse who provides services is acting both as a health professional and a citizen. She is responsible for respecting the rights accorded her clients under the Charter.

Civil Code of QuébecThe Civil Code of Québec contains basic provisions governing life in society, i.e. relations between persons and between persons and property. It deals with the status of individuals and their capacity, the organization of the family, contracts, civil liability and property.

The Civil Code gives clients rights that nurses must respect, in particular:

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the � right of a person not to be made to undergo care without his free and informed consent. If the person concerned is incapable of giving or refusing his consent, the Code specifies who may act in his name;

the � right of a person to have access to his records and to make corrections to the information in those records. Information in a patient’s record may not be disclosed by a professional without the consent of the person concerned.

Act respecting health services and social services (AHSSS)In Quebec, the rights of users of health services are recognized in the Act respecting health services and social services. They include:

the � right to information on the existence of the health and social services and resources available in his community and of the conditions governing access to such services and resources;

the � right to receive, with continuity and in a personalized and safe manner, health services and social services which are scientifically, humanly and socially appropriate in view of the resources available;

the � right to choose a professional and an institution that will provide these services, in view of the organization of services at the institution and the availability of resources;

the � right to receive appropriate care in an emergency;

the � right to be informed of his state of health and welfare, the options available in view of this state and the risks and consequences associated with each option, before consenting to care. Users are also entitled to be informed, as promptly as possible, of any accident that occurred during the delivery of services which is likely to have or which has had a significant impact on his state of health or personal integrity;

the � right to consent to or refuse to undergo care;

the � right to participate in any decision affecting his situation;

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the � right to be accompanied or assisted by the person of his choice when seeking to obtain information on the services offered or to file a complaint;

the � right to services in the English language for English-speaking persons, insofar as there is an access program for these services for the region in question;

the � right to have his records remain confidential;

the � right of access to his records;

the � right to recourse in case of professional or other negligence.

The Organization and Management of Establishments Regulation was adopted pursuant to the AHSSS. In the fifth chapter it deals with setting up and keeping records on beneficiaries in institutions, the contents of medical records, archiving records and their access and the contents of consent forms for surgery and anesthesia.

Other acts contain provisions applicable to nursing in Quebec, in particular:

Act respecting the protection of persons whose mental state presents a danger to themselves or to othersThe provisions of this act complement those of the Civil Code. It deals with provi-sional confinement ordered by a tribunal with a view to psychiatric assessment and provides, in emergencies, that a person may be confined against his will and without court authorization if his mental state presents a grave and immediate danger to himself or to others.

The Act also imposes rules of procedure to ensure that the person concerned and his close relatives receive complete information and follow-up on the rights of and remedies available to the person under confinement.

Youth Protection ActAccording to the Youth Protection Act, the primary responsibility for children rests with their parents. In some cases, however, the State must intervene, when the security or development of a child is in danger. In such cases, the Act

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stipulates that any intervention in respect of a child and his parents must be designed to put an end to and prevent the recurrence of a situation in which the security or development of the child is in danger. This act applies to young people under age 18.

Act respecting Access to documents held by public bodies and the Protection of personal informationThis act has two main objectives: it guarantees access to documents held by public bodies and confirms the principle of the confidentiality of personal information files held by public bodies. The provisions relating to nurses’ obligations fall mainly under this second aspect of the Act.

Nurses must be familiar with the relevant sections of these acts. They are pre-sented in Appendix II.

Nurses’ professional liability

If a nurse commits a breach in delivering nursing care that results in harm, she incurs not only professional but also civil liability. To determine whether her behaviour was negligent in terms of civil law, the tribunal considering a suit for damages must establish, in light of all the rules governing the profession, what another reasonably prudent, diligent and competent nurse would have done under the same circumstances. To conclude in favour of the plaintiff, the tribunal must also decide that the plaintiff actually suffered damages that were the result of the nurse’s acts or omissions.

Ignorance of the law or of standards relating to the delivery of nursing care is not a valid defence. Thus it is imperative that all nurses be familiar with the acts, regulations and standards of practice that they must respect on a daily basis in their practice. In case of doubt regarding her knowledge or skills, a nurse is obliged to obtain the assistance, support, supervision or training she needs.

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ReadingTo help you understand the provisions of legislation relating to the practice of nursing, take the time to read the excerpts from the acts and regulations in Appendix II. You will also have to refer to them for the following exercises.

ExErcisE 2.1

Identifying and applying acts and regulations

The rights conferred on clients by Quebec legislation impose obligations on nurses that they must respect in their daily practice. The situations below will help you understand nurses’ legal obligations relating to client rights, in particular:

the right to personal integrity; �

the right not to be made to undergo care without free and informed �consent;

the right to respect of confidentiality; �

the right to receive care in an emergency; �

the right to be informed of any accident or incident that could have �consequences for their health;

the right to have access to their records. �

Once you have completed the exercise, you can check your answers by consul ting the answer guide on page 109.

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Situation 2.1 1

Mrs. Moreau, 74 years old, lives in a residential centre for people with decreased levels of autonomy. Every year, the centre holds a flu vaccination clinic, as recommended in the Quebec Immunization Protocol. The nurse in charge of vaccinations checks with her client whether she wishes to be vaccinated.

What would be the appropriate professional conduct in this situation? Explain your answer, referring to the provisions concerning free and informed consent in the Civil Code of Québec and the Code of Ethics of Nurses.

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Situation 2.1 2 a

Veronica is a night nurse on the emergency ward in a hospital. She sees Stella, a 15-year-old, who is accompanied by a girlfriend. Stella is pale and has been expe-riencing severe abdominal pains since having an abortion in a clinic the day before. Based on the results of the ultrasound, the doctor wants to conduct a laparoscopy. Stella asks the nurse not to tell her parents about her situation.

What would be the appropriate professional conduct in this situation? Explain your answer, referring to the provisions concerning free and informed consent in the Civil Code of Québec.

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Situation 2.1 2 b

Stella has a uterine perforation, which requires a blood transfusion. She has been under observation at the hospital for 14 hours, and the doctor wants to keep her 24 hours longer. He tells her parents, who are surprised that they were not informed of their daughter’s hospitalization and treatments.

a) Explain why the doctor informed Stella’s parents at this point, referring to the provisions concerning consent required for the hospitalization of a minor in the Civil Code of Québec.

b) What would have happened if Stella’s condition had required emergency surgery? Explain your answer, referring to the provisions of the Civil Code of Québec and the Charter of Human Rights and Freedoms.

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Situation 2.1 3

Irene, a 34-year-old homeless drug addict, is admitted to the psychiatric ward. She is agitated and confused. She is hurting herself and acting aggressively toward other clients.

What provisions of the Act respecting health services and social services can the nurse use in deciding on the appropriate means of control to protect the client?

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Situation 2.1 4

Mr. Janvier, 76 years old, is a new resident at the long-term care facility. His heart condition is worsening, and he must be transferred to the hospital, 40 minutes away. The nurse at the residential centre decides, without a medical prescription, to install an intravenous catheter and an IV drip to keep his veins from collapsing.

Is the nurse allowed to make this decision? Explain your answer, referring to the provisions of the Civil Code of Québec and the Charter of Human Rights and Freedoms.

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Situation 2.1 5

Sonia, a 16 year old who is using injectable drugs, is brought to the hospital by the police. She has had an overdose and is in need of emergency care. Her parents ask the nurse to let them see their daughter’s record.

What should the nurse do in this situation? Explain your answer, referring to the provisions of the Charter of Human Rights and Freedoms, the Act respecting health services and social services, and the Act respecting Access to documents held by public bodies and the Protection of personal information concerning the confidentiality of patient records.

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Situation 2.1 6

Carl is hospitalized for multiple fractures sustained in a suicide attempt. His record indicates that he has had many stays in detoxification centres and has also had run-ins with the police for selling drugs. The orderly, who is providing the basic care, asks the nurse about Carl’s background.

What is the nurse allowed to tell the orderly? Explain your answer, referring to the provisions of the Charter of Human Rights and Freedoms, the Act respecting health services and social services, and the Act respecting Access to documents held by public bodies and the Protection of personal information concerning the confidentiality of patient records.

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Situation 2.1 7

Mr. Lee lives in a long-term care facility, where he was admitted because of a reduction in his level of autonomy. His health situation has been stable for several weeks.

In this situation, what are the nurse’s obligations with respect to documenting his care? Explain your answer, referring to the provisions concerning the documentation of care in the Organization and Management of Establishments Regulation under the Act Respecting Health Services and Social Services.

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Situation 2.1 8

For the second time this month, a woman shows up at the hospital emergency clinic with her 10-month-old baby, saying he fell out of bed. The nurse notes that the mother is very talkative, her pupils are dilated and she has numerous needle marks in her forearm. When the nurse asks her about her condition, she says she lives alone with her child because the father is working abroad. The child is pale and thin and has numerous bruises. The client’s record notes suspicious marks on the child in the past.

What would be the appropriate professional conduct in this situation? Explain your answer, referring to the Youth Protection Act.

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Situation 2.1 9

Following an episode of post-operative bradypnea, Chantal, the nurse, dis-covered a dosage error in the intravenous administration of morphine by the nurse previously caring for the client.

a) Once all the steps have been taken to ensure the client’s safety, including notifying the physician, is Chantal obliged to report this accident? Explain your answer, referring to the Act respecting health services and social services.

b) Must the client be informed of this accident? Explain your answer, referring to the Act respecting health services and social services.

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Situation 2.110Mr. Ambrose was brought to the emergency clinic following a violent street fight. He is admitted to the psychiatric ward. He has had bipolar disorder for many years now, and is currently in the manic phase. The nurse notes that he is extremely excited and unable to concentrate. He skips from one idea to the next and his mood shifts from euphoria to aggression. He says he has to settle things with the people who beat him up and wants to sign a refusal of treat-ment and leave the hospital immediately. Since the psychiatrist’s assessment shows that there is a risk to the client’s safety, a request that he be confined to the institution is made. Mr. Ambrose is angry and says he is being hospitalized against his will, and that his independence is not being respected. He asks the nurse to help him.

a) What provisions of the Act respecting the protection of persons whose mental state presents a danger to themselves or to others is the doctor using when he requests that Mr. Ambrose be confined to the institution?

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b) Referring to the Act respecting the protection of persons whose mental state presents a danger to themselves or to others and the Civil Code of Québec, what information can the nurse give Mr. Ambrose about his rights in this situation?

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ExErcisE 2.1

Situation 2.1 1Answer: Mrs. Moreau is an autonomous person who is capable of making her

own decisions. Clients have the right to expect truthfulness, personal respect and recognition of their decision-making power, so the nurse is required to obtain her free and informed consent before vaccinating her.

Article 11 of the Civil Code of Québec (C.c.Q.) clearly states the obligation to obtain this consent from clients before providing care. A person cannot be subjected to care, be it an examination or treatment, giving samples or any other intervention, without his consent. Health professionals are not authorized to make decisions about treatment in their clients’ stead, except in emergencies.

The nurse also has ethical obligations concerning consent. According to section 41 of the Code of Ethics, when a nurse is responsible for obtaining free and informed consent, she must provide the client with all the information required for that purpose.

Consent is the manifestation of express or tacit willingness by which an individual approves an act to be performed by another person. The client’s consent may be implicit or explicit and may be expressed either in writing or orally.

Consent is explicit when it is clear and specific. Consent is implicit when it is not expressed formally, but the context makes it possible to assume that the person consents. It is considered to be understood.

A nurse who is offering care to her client is responsible for assessing the client’s ability to make a decision concerning the care. Remember that the obligation to obtain consent is an ongoing process; clients may withdraw their consent at any time and are entitled to refuse treatment. Even if the nurse has obtained the client’s explicit consent, she must always explain the intervention she is carrying out.

answer guide

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Answer:(Situation 2.1.1, cont’d)

To be valid, this consent to care must meet two requirements: it must be given freely and it must be informed. Consent is free when it is given readily with no constraint. It is not free if the decision is the result of pressure applied by another person in the form of a moral or physical constraint.

Consent is informed when it is given on the basis of proper informa-tion. This requirement means that nurses have a duty to inform clients and the Code of Ethics stipulates that to do so they must provide clients with all the information required for that purpose. In theory, this duty to inform applies to what clients need to know to make an informed decision. This does not mean that nurses have to tell them absolutely everything, but enough so that clients understand what is at stake for them, in a language they understand.

They must provide information on six points: the proposed care, other possible solutions, expected benefits, risks and side effects, and conse-quences if the client refuses. In this case, the nurse must answer the client’s questions about the vaccination. It is advisable to keep notes in the file on the information provided and the client’s decision, including when she refuses the care offered.

In providing information about the vaccination, the nurse must refer to the Quebec Immunization Protocol, the tool for carrying out all aspects of the provincial public health program concerning immunization. It is available on the Website of the Department of Health and Social Services (MSSS) at www.msss.gouv.qc.ca, in the “Santé publique” section. Click on the “Vaccination” tab and then on “Professionnels santé.”

This rule of free and informed consent applies to all clients. Obviously, a person who is able to give consent will do so himself. However, if a person is incapable of giving his consent because of his age or inability to express his wishes or understand the consequences of his actions, another person must do so in his stead (e.g. tutor, public curator, spouse). This is known as substitute consent (C.c.Q., art.11).

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Situation 2.1 2 aAnswer: The client has to undergo a laparoscopy, which requires consent before

the operation. Minors ages 14 and over may consent alone to care required by their state of health (C.c.Q., art.14). Consequently, the nurse must not inform Stella’s parents.

Situation 2.1 2 ba) Answer: The Civil Code provides that if a minor 14 years or over remains in the

hospital for longer than 12 hours, his parents must be informed. Stella’s doctor notified her parents of her hospitalization because she has been in the emergency ward for 14 hours. The reason for her hospitalization remains confidential, however. The law gives minors 14 years and over the right to consent alone to care required by their state of health (C.c.Q., art.14).

b) Answer: If emergency surgery had been required, article 13 of the Civil Code would have applied: Consent to medical care is not required in case of emergency if the life of the person is in danger or his integrity is threatened and his consent cannot be obtained in due time. In addition, section 2 of the Charter provides that every person must come to the aid of anyone whose life is in peril.

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Situation 2.1 3Answer: Section 118.1 of the Act respecting health services and social services

(AHSSS) stipulates that restraint or isolation are to be used as a last resort and only to prevent a person from inflicting harm upon himself or others.

A nurse may decide to use restraint without a medical prescription, if the establishment has a policy to that effect. The nurse responsible for caring for Irene will have to indicate in the therapeutic nursing plan what measures are to be taken to protect the client and other clients in the care unit and how they are to be applied.

This reserved activity is part of a systematic approach aimed at reducing the use of restraint by first applying effective and efficient replacement options that are respectful of the individual and his autonomy, environ-ment and friends and family. Recourse to restraint calls for a thorough assessment of the person’s health situation and the prior use of other measures, close supervision and constant re-assessment of its relevance, according to the procedure for the application of control measures adopted by the hospital.

The nurse may consult the Ministerial guidelines on exceptional use of restraint, isolation and medication (Orientations ministérielles relatives à l’utilisation exceptionnelle des mesures de contrôle: Contention, isole-ment et substances chimiques) and the associated action plan. These documents are available on the MSSS Website at www.msss.gouv.qc.ca, under “Documentation,” “Publications.” The MSSS has also developed a course entitled Vers un changement de pratique afin de réduire le recours à la contention et à l’isolement (“Toward changing practices to reduce the use of restraint and isolation measures”).

The Act also states that no person may be made to undergo care except with his consent (AHSSS, s. 9). This provision is in line with the principles of inviolability of the person and the right to integrity in the Civil Code (C.c.Q., art. 10, 11). In Irene’s situation, the nurse will have to obtain her consent, if she is able to give it, or else substitute consent.

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Situation 2.1 4Answer: Given section 2 of the Charter of Human Rights and Freedoms and the

first paragraph of article 13 of the Civil Code, which provide that pro-tecting someone’s life and physical integrity requires that assistance be given and the required care provided when his life is in danger, the nurse must rapidly install an IV catheter.

In view of Mr. Janvier’s worsening heart condition and the 40-minute trip to the hospital, his veins could collapse and compromise the care required when he arrives at the hospital, threatening his life and physical integrity.

Situation 2.1 5Answer: Although Sonia is a minor (under 18), she is entitled to keep informa-

tion concerning her confidential and divulge or share it with whomever she wishes. The information in a client’s record is confidential, and the client has not waived her right to secrecy of confidential information. Her nurse is obliged to take the necessary steps to maintain the confi-dentiality of information concerning her client, and so must refuse to allow her parents access to their daughter’s record.

“The record of a user is confidential and no person may have access to it except with the consent of the user […]” (AHSSS, s. 19). Moreover, section 59 of the Act respecting Access to documents held by public bodies and the Protection of personal information confirms the right to confi-dentiality, as do sections 5 and 9 of the Charter, which state that every person has a right to respect for his private life and to non-disclosure of confidential information.

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Situation 2.1 6Answer: The right to respect for one’s private life and to non-disclosure of con-

fidential information are stipulated in sections 5 and 9 of the Charter. In addition, the Act respecting health services and social services and the Act respecting Access to documents held by public bodies and the Protec-tion of personal information state that information in a user’s record is confidential. Consequently, the orderly, who is not part of the clinical staff, is not entitled to information in Carl’s record.

In accordance with section 62 of the Act respecting Access to documents, the nurse may not provide the orderly with any information other than that necessary to provide the care required by the user’s health. Carl has spent time in detoxification centres and had run-ins with the police. Since this information is not necessary to provide basic care, the nurse must not disclose these details to the orderly.

However, if the nurse noted a risk of suicide and instructed the orderly to help provide the necessary supervision, she could then give him the information necessary for this purpose. She would then discuss the behaviours to watch for in Carl. The Act provides that information in a client’s record may be communicated, in order to prevent an act of vio-lence, including a suicide, without the client’s consent (AHSSS, s. 19.1).

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Situation 2.1 7Answer: Documentation refers to all the information relating to nursing care

placed in the client’s record and the action of recording this informa-tion. The nurse caring for Mr. Lee at the centre must keep progress notes, including the therapeutic nursing plan (TNP), by providing enough infor-mation to ensure continuity of care for the client. The documentation must include information making it possible to follow the evolution of Mr. Lee’s health situation, note any changes and measure the effec-tiveness of any interventions.

Section 55 of the Organization and Management of Institutions Regulation states that records kept by a long-term care facility must include progress notes by physicians, dentists, pharmacists and members of the clinical staff, including nurses. Healthcare institutions have rules concerning documentation methods and tools and even the minimum frequency in certain cases, such as long-term care. Whatever the procedure established for documenting nursing care is, it must contribute to the continuity of care and make it easy to assess the quality of nursing care, with the goal of continuously improving the service provided for clients. For further details, nurses may consult the following OIIQ publi cations:

Énoncé de principes sur la documentation des soins infirmiers. �

A guide to the various daily activities involved in documenting nursing care.

L’intégration du plan thérapeutique infirmier à la pratique clinique. � Guide on the documentation standard regarding the therapeutic nursing plan and its application.

From a legal point of view, the information placed in the client’s record could be important evidence in a dispute. If a record is lost or incomplete, the court may conclude that the care not recorded was not given, and that the nurse was negligent.

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Situation 2.1 8Answer: The nurse has reasonable grounds to believe that the 10-month-old baby

has been neglected or abused. She is required to report this situation to the Director of Youth Protection, in accordance with section 39 of the Youth Protection Act. The Act prescribes the obligation to report to the Director of Youth Protection any situation in which the security or development of a child is or may be considered to be in danger. It expressly provides that under such circumstances secrecy of confi-dential information is not an obstacle to fulfilling this obligation and that anyone who makes such a report in good faith cannot be prosecuted. This is one of the two exceptions provided in section 9 of the Charter of Human Rights and Freedoms. This section provides that a professional bound to secrecy of confidential information may disclose confidential information only when authorized to do so by the person who confided such information to him or by an express legal provision.

As specified in the Charter and the Professional Code, there are only two situations in which nurses may disclose information protected by professional secrecy:

1. With the client’s authorization The secrecy of confidential information belongs to the client who gives the information. He is the one who holds this right to confidentiality. In the situation described, the mother did not talk to the nurse about any behaviour that could threaten her child’s safety.

Clients may waive, in whole or in part, their right to secrecy of confi-dential information. This renunciation may be explicit or implicit. It is explicit when it explicitly or formally authorizes the professional to divulge to a third party all or some of the information. The profes-sional must comply with this requirement, in accordance with the conditions set by the client.

Clients may also implicitly waive this right. For instance, if a person consulting a nurse is accompanied by a family member, he implicitly waives his right to confidentiality as it pertains to the family member, but only as concerns the information communicated in the presence of the family member.

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Answer: (Situation 2.1.8 cont’d)

2. Where bound by law There are a number of legal provisions that authorize or require a professional to disclose information to third parties without the client’s authorization. This situation of the mother who has brought her 10-month-old baby to the hospital meets the exceptional conditions allowing disclosure as set out in section 39 of the Youth Protection Act. The emergency nurse who saw the baby and noted that his security could be in danger is justified in immediately reporting this situation to the Director of Youth Protection.

Situation 2.1 9a) Answer: The nurse must, as soon as possible after becoming aware of any inci-

dent or accident, report it to the executive director of the institution or to a person designated by the executive director (AHSSS, s. 233.1). This report is intended to prevent avoidable medical accidents, and must be made using the form provided for such purposes and placed in the client’s record.

b) Answer: Since the medication error had consequences on the client’s respiratory state, he is entitled to be informed of the accident. The Act states that the client has the right to be informed of any accident that has actual or potential consequences for his health or welfare (AHSSS, s. 8).

The purpose of these legal provisions is to enable the Quebec health network to make risk management a priority, so as to prevent avoidable accidents in the provision of health care.

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Situation 2.110a) Answer: In accordance with section 7 of the Act respecting the protection of per-

sons whose mental state presents a danger to themselves or to others, the doctor may temporarily place a person under preventive confinement without his consent and without court authorization. In Mr. Ambrose’s case, the doctor considered that his mental state presented a serious and immediate danger to himself or others. For his own protection, the client is confined to the institution until the court makes a decision in his case. The doctor must immediately notify the director of professional services of the situation.

b) Answer: In accordance with section 15 of the Act respecting the protection of persons whose mental state presents a danger to themselves or to others, Mr. Ambrose must be informed of the reasons for his confinement and of his right to contact his close relatives and an advocate. The nurse must inform the client of his right to receive information on his care and on his confinement in the institution and of his right to consult an advocate regarding this confinement.

The Civil Code of Québec provides that consent to medical care is not required in case of emergency if the person’s life is in danger (art. 13). Although Mr. Ambrose is legally able to give consent, he cannot exercise this right for the moment, given the danger he presents to himself. The nurse must explain to him that he is being confined to the institution for his safety so that the treatment necessary to better assess the care required for his well-being can be undertaken. Confining Mr. Ambrose by force constitutes interference with his personal integrity. The nurse responsible for his care must do her best to mitigate this interference, by ensuring that all his rights are respected.

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Section 3

considerationsother ethical

The final section of the self-study guide looks at other ethical considerations for nurses in Quebec.

This part deals with nurses’ ethics as well as personal and professional values. It also includes exercises that call for considering the Code of Ethics of Nurses, clients’ rights and the legislation governing nursing practice.

for Quebec Nursesconsiderationsconsiderationsconsiderationsconsiderationsconsiderationsconsiderationsconsiderationsconsiderationsconsiderationsconsiderationsconsiderationsconsiderationsconsiderationsconsiderationsconsiderations


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Fundamentals

Ethics

In this guide the term “ethics” refers to a way of thinking about values and standards concerning professional conduct. It is “applied ethics,” calling for dialogue and an open mind.

In ethics, values reflect the importance assigned to beliefs, ideas, attitudes, cus-toms or traditions and objects. They reflect needs, social and cultural influences and relations with other people. Generally speaking, a person’s values evolve as she acquires maturity and life experience, and continue to guide her actions. This evolution often leads to changes in the priority or importance assigned to certain values, leading to changes in attitudes and behaviour.

As she strives to clarify her values, she comes to better understand the choices she makes and the reasons for her actions. This exercise develops her discern-ment and prudence, two prerequisites for openness to others and the ability to accept diverging opinions, overcome resistance and sustain dialogue.

Reflecting on her personal and professional values prepares a nurse to under-stand the values of clients and their families as well of those of her colleagues, and to interact appropriately in situations when values are or appear to be in conflict.

Personal and professional values

Personal values have an influence on the choice of a profession. It is recognized that nurses have profound respect for the individual and for life, and that they are naturally disposed to express this respect in their professional conduct. Most often a nurse’s personal values are in line with professional values.

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The Code of Ethics of Nurses is inspired by the values essential to ethical nursing practice. In addition to respecting the unique and inviolable character of the individual, nurses show compassion and place great importance on the quality of services and care they provide. They respect others’ independence, private lives and quality of life. Clients’ well-being and safety are at the heart of nurses’ concerns, along with justice and equity in providing care.

Nurses also recognize the importance of maintaining a relationship of trust with their clients. They strive to collaborate with other health professionals and hence value the concepts of responsibility and accountability linked to profes-sional independence. They feel that competence and the quality of nursing care are inseparable and consequently see it as essential to keep their knowledge up to date. These professional values are reflected in the delivery of care and in relations between nurses and their clients.

The following section contains a number of exercises dealing with the values that apply to nursing in Quebec. These values are defined below, so that you can refer to them while doing the exercises.

Definitions of values

compassionThe sentiment or attitude of wishing to comfort and assist another person who is suffering in some way.

competenceThe knowledge, skills, attitudes and judgment a nurse needs to practise her profession and her ability to apply them in practice.

integrityA fundamental value considered to be the cornerstone of ethical duty, guiding a nurse’s attitudes and behaviours toward her clients. This is reflected in her candour, honesty and fairness.

interprofessional collaborationA situation in which various health professionals work together in the client’s best therapeutic interests.

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Justice and equityMoral qualities that allow a nurse to treat clients objectively, so they receive the share of health services and resources to which they are entitled, in accor-dance with their needs.

Professional independenceThe ability to make the necessary professional decisions, appropriate to the situation (responsible) and to be accountable for them.

Relationship of trust with clientsThe establishment, development and maintenance of a professional relation-ship of trust with clients, allowing them to confide in the nurse with complete confidence.

Respect for human dignityRecognition of the unique and inviolable character of a human being, from the beginning to the end of his life.

Respect for human lifeRecognition of the importance of protecting human life.

Respect for privacyRecognition of a person’s right to be spared any unwanted intrusion into his private life, so as to protect his interests and physical, psychological, spiritual and cultural integrity.

Respect for quality of lifeRecognition of the obligation to pay particular attention to the client’s health and well-being, as he sees it and expresses it according to his own standards.

Safety A situation in which there is no danger or in which the person feels safe, that she has nothing to fear and can trust those around her.

Self-determination A person’s ability to make decisions independently concerning herself.

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ExERciSE 3.1

Determining values

In order to recognize a conflict in values, you must first identify the values involved.

Referring to the above definitions, identify the values at work in the three situations below. Once you have completed the exercise, you can check your answers by consulting the answer guide on page 129.

Situation 3.1 1

Nadia is a 23-year-old nurse. She has just discovered that she is pregnant. She has been living with Mark for two years, and supporting him while he completes his studies in engineering.

They had decided to start a family once Mark completes his degree and finds a job. This was an unplanned pregnancy. Nadia is uncomfortable. She wants the child, but Mark would rather wait until he has finished his studies. He suggests that she have an abortion and promises to be there for her. Nadia can’t accept this solution.

She has talked the situation over with him openly a few times. She tells him she wants to have the child and her arguments are in favour of continuing her pregnancy. She says that she finds the idea of abortion repugnant and that the life she is carrying deserves to be protected. She feels privileged to be fertile, unlike her sister, who is unable to have children despite many treatments. She feels that although this is not an ideal time to have a child, it would be selfish to sacrifice the child’s life so as not to compromise the quality of their life as a couple. On the other hand, she is aware of the risk that she could lose her partner if she decides to have the child against his wishes. Nadia tells Mark that she is psychologically ready to bear the child, that she doesn’t think that he is ready for this, but that she is determined to have the child.

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a) What value is guiding Nadia’s actions in this situation?

b) What value is guiding Mark’s actions in this situation?

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Situation 3.1 2

During her postpartum follow-up home visits, a nurse encourages new mothers to breastfeed. One of the mothers she visits wants to stop breastfeeding her newborn. An evaluation of the situation confirms that the client has made an informed decision that meets her needs and conforms to her values. The nurse explains how to wean the baby and gives her advice to ease the transition to bottle feeding.

a) What values are guiding the nurse’s professional conduct in this situation?

b) Explain your answer.

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Situation 3.1 3

A nurse who has worked in mental health for 10 years is transferred to the major burns unit after her position is abolished. She is aware that her new assignment calls for specialized skills if she is to provide quality care. At her meeting with the new department head, she tells him that she needs to update her know-ledge and outlines the steps she has taken to find an appropriate educational setting. She tries to negotiate intensive, short-term remunerated training. The department head studies her proposal.

a) What values are guiding the nurse’s professional conduct in this situation?


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Situation 3.1 4

An elderly homeless man with serious psychiatric problems and hallucinations is brought to the emergency clinic by ambulance. The client presents with a very foul body odour and talks loudly and incoherently. The emergency staff knows him already, as he has been admitted several times in the past to the psychiatric ward to treat his schizophrenia. His behaviour creates a stressful atmosphere in the care unit.

a) What values should guide the professional conduct of the nurse assigned to the client in this situation?


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ExERciSE 3.1

Situation 3.1 1a) Value: The value guiding Nadia’s actions is respect for human life.

She clearly states the main value guiding her choice that is her respect for the life growing inside her. She also bases her choice on her desire to have the child and her ability to ensure the baby’s security and well-being. She also considers her fertility a privilege.

b) Value: Mark’s actions are guided by the principle of quality of life.

He sees his quality of life as more important and feels that it would be upset by the arrival of a baby. His priority now is to obtain his engi-neering degree. The quality of the couple’s relationship is an indispen-sable element in his pursuit of his professional goals. The arrival of a baby would compromise his quality of life.

Situation 3.1 2a) Values: The values guiding the nurse’s professional conduct are competence,

her relationship of trust with the client, and respect for the client’s right to self-determination.

b) Explanation: Although the nurse encourages breastfeeding, she respects the client’s decision, after confirming that the client has made an informed deci-sion and can take responsibility for it. She offers the client her expertise, clearly explaining how to wean the baby and switch to bottle feeding, so as to ensure the baby’s health and well-being.

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Situation 3.1 3a) Values: The values guiding the nurse’s professional conduct are competence

and professional independence.

b) Explanation: The nurse recognizes the limits of her competence in caring for major burn patients. She is also able to evaluate her training needs herself and discusses them openly with her employer. She recognizes that it is her responsibility as a professional to keep her knowledge and skills up to date so as to practise safely and competently. She acts conscientiously by suggesting solutions.

Situation 3.1 4a) Values: The values that guide the nurse’s professional conduct are respect for

human dignity, justice and equity.

b) Explanation: The nurse provides the client with care regardless of his social situation. She respects his needs and ensures that he receives the care required by his state of health. She respects the client’s well-being, while thinking about the well-being and safety of other clients in the care unit.

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ExERciSE 3.2

Recognizing conflicting values

A conflict in values is a difference of opinion arising from opposing values, beliefs or tastes, different personality types or social norms.

Nurses usually share professional values that correspond to their personal values. Sometimes these values do not match, and give rise to conflict.

A conflict in values can occur within the healthcare team, when there is a difference of opinion between clients and professionals, between professionals or between clients and family members. To solve the conflict, it is important first of all to identify the opposing values. This is an essential skill that nurses must acquire and develop to solve conflicts in values that can occur in their professional practice.

In the following three situations, determine the values involved and explain how they are conflicting. Once you have completed the exercise, you can check your answers by consulting the answer guide on page 138.

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Situation 3.2 1

A nurse is talking about palliative care with a man in the terminal phase of his illness. He has been a widower for three years and has four children. The nurse has been caring for him for several months and is well aware of his physical and mental suffering. He is very troubled by his approaching death, and asks the nurse to help him. He tells her that he does not want to be resuscitated. He asks her about possible options if he can no longer drink nor eat. After listening to her explanations, he says that he refuses to receive intravenous fluids, that he does not want to prolong his suffering. The nurse records his wishes in his file and recommends that he tell his children, so that they are ready for this situation.

After a few weeks, the client’s condition worsens. He is not eating and has great difficulty drinking. His periods of lucidity are increasingly rare. The family has trouble dealing with this situation and asks that an intravenous drip be installed, regardless of their father’s wishes. They feel that intravenous hydration is a question of comfort that should be given their father in his last hours.

The nurse reiterates the client’s wishes concerning hydration. She knows that it is her role to have the client’s wishes respected and to help his family cope with this final phase in their father’s life as easily as possible. She feels uncomfort-able about the situation and wonders about the conflicting values.

Explain the conflicting values facing her in this situation.

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Situation 3.2 2

Tania, a young teenager, consults the CLSC nurse about an abortion. She wants to continue her college studies. Her boyfriend is also a student, and both of them live at home. Tania says she has always wanted children, but that her current social and financial situation means that she wouldn’t be able to offer her child the proper quality of life. Her parents are well off and have offered to support her financially if she keeps the baby. According to their religious beliefs, they must encourage their daughter not to have an abortion.

Tania does not want to submit to her family’s wishes. She worries about being too dependent on her parents. Her boyfriend feels that an abortion is the right solution at this time. Tania worries about grieving over her unborn child to such an extent that it could interfere with her studies and her relationship with her boyfriend. She asks the nurse to explain what happens after an abortion.

Maria, the CLSC nurse, had a similar experience with her own daughter. She had encouraged her daughter to keep her child and offered to support her. Maria feels that life is sacred and that parents have a duty to encourage their children not to have abortions.

a) Explain the conflicting values facing the nurse in this situation.

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b) What value guided Maria’s conduct with her own daughter?

c) What value should guide Maria’s professional conduct with Tania, the teenager who is not her daughter?

d) What professional conduct should Maria adopt with the teenager who is not her daughter?

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Situation 3.2 3

During a meeting at a long-term care facility, the multidisciplinary team dis-cusses the choice of residents to be taken on an outing to a sugar shack. Several of them have requested to go.

The five-hour outing means using adapted transportation, and is very tiring for the accompanying staff. The health professional in charge of the activity says that she wants to avoid overworking the accompanying staff, so as to ensure everyone’s safety.

The nurse mentions the special case of one resident who recently had a stroke and has been making good progress in his bladder re-education. She thinks that refusing to take him on the outing could affect his morale. For the past month, his episodes of urinary incontinence have occurred only rarely, in the early morning. In addition, when he takes part in activities at the centre he sometimes wears adult diapers as a precaution.

The resident is very keen to go on the outing, especially since it is in the village where he was born. He has gone to the sugar shack every year since he was a boy, and this trip would mean a lot to him. He thinks that he can take part without being a burden on the staff. The nurse asks the team to reconsider his request, as he will see it as encouragement for the progress he has made.

The health professional hesitates to add this resident to the group. She wants to avoid overworking the staff, as this could compromise the group’s safety. The nurse suggests that the resident be allowed to go, provided that he respects his urination schedule and agrees to wear an adult diaper. In the end, the resident is allowed to go along on this outing that is so important to him.

Explain the conflicting values facing the nurse in this situation.

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ExERciSE 3.2

Situation 3.2 1Explanation: This is a conflict between the client’s values and those of his children,

between his right to self-determination and their respect for his well-being.

The nurse wants to respect the client’s last wishes, as he was capable of deciding for himself when he made them, in particular his refusal of resuscitation and IV hydration.

She respects his right to self-determination: he made a free and informed choice concerning possible treatment at the end of his life.

She also understands the client’s children when they ask for IV hydra-tion, even though they know it goes against their father’s last wishes. They feel that it is a matter of respect for his well-being. Their father’s independence is in question.

The end of a person’s life is difficult for all concerned. The client expressed his wishes concerning his terminal treatment. It is important that the family understand the reasoning of the person who has reached the terminal phase of his illness, so as to accompany him at this time. The nurse must advocate the client’s viewpoint, since he is no longer able to make himself heard to his family.

Situation 3.2 2a) Explanation: This is a conflict between the nurse’s personal and professional values:

respect for human life and the client’s right to self-determination.

In her personal and family life, the nurse gives priority to respect for human life. She finds herself in a clinical situation in which the teenager she has a duty to help has values different from her own. Her personal values are in conflict with her professional values that require her to respect the client’s right to self-determination.

b) Personal value: The value that guided Maria’s conduct with regard to her own daughter is respect for human life.

answer guide

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c) Professional value: The value that must guide Maria’s professional conduct with Tania is respect for the teenager’s right to self-determination.

d) Professional conduct: Maria must set aside her personal values and adapt her professional conduct to the duties and obligations spelled out in section 30 of the Code of Ethics of Nurses. She must comply with the teenager’s wishes, after making sure that she has properly thought through her decision.

Situation 3.2 3Explanation: This is a conflict between the nurse’s own values and those of the health

professional: respect for the resident’s quality of life, and the safety of all participants. The nurse argues in favour of the resident’s qualify of life, citing the progress he has made in his bladder re-education, so that he can enjoy an experience that means a lot to him.

The health professional emphasizes the safety of the residents going on the outing, by excluding an incontinent resident who could overwork the accompanying staff and jeopardize the safety of the group.

Thanks to interprofessional co-operation, a solution was found so that the resident could take part in the outing without jeopardizing the others’ safety: he must respect his urination schedule and wear an adult diaper during the outing.

Regardless of whether the health professional is a physician, a physio-therapist or another professional, a conflict in values can be resolved provided that the professionals involved work together to meet the client’s needs and keep his interests in mind.

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ExERciSE 3.3

Determining the appropriate professional conduct in situations involving ethical issues

In this last part of the section dealing with ethics, you will be asked to consider both the provisions of the Code of Ethics of Nurses and the applicable legisla-tion as you study two clinical situations in which the values of the persons concerned may conflict (health professionals, caregivers, clients and significant others).

We recommend that you use the ethics worksheet to help you determine the appropriate professional conduct when there is a problem involving ethics in a clinical situation.

The first step is to recognize the conflict in values, by identifying significant clues and specifying the nature of the ethical problem. To do so, read the description of the situation and identify obvious or probable signs of a conflict between personal and professional values, a conflict between the nurse’s values and those of the client and his family, or a conflict between the nurse’s values and those of her colleagues. Then identify the conflicting values that are creating discomfort either on the part of the client and his family or within the healthcare team.

The second step is to examine the ethical problem in light of the applicable regulatory framework, i.e. the relevant provisions of the Code of Ethics of Nursesand legal conside rations, including client rights.

The third step is to decide on a strategy, i.e. the actions to be taken to foster dialogue between the individuals concerned in the client’s best interests. This strategy must be consistent with the applicable regulatory framework you have identified.

You have two situations to examine. After reading the description of the situa-tion, complete the ethics worksheet, following the three steps described above to determine the appropriate professional conduct in the situation.

You can then compare your answers with the explanations provided in the annotated worksheet by consulting the answer guide on page 148. There are no right or wrong answers in applied ethics. You are looking for the best line of

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conduct, or the least harmful one in the circumstances. This exercise is intended to encourage you to think about how to deal with a clinical situation involving an ethical problem.

In complex ethical situations, nurses may consult the clinical ethics committee of the institution, which is responsible for analyzing clinical cases that raise specific ethical problems. The committee draws up guidelines reflecting the applicable legislation and ethical principles to guide the conduct and attitudes of all concerned.

For issues relating to research, a research ethics committee at the institution makes sure that projects respect the dignity, well-being and rights of research subjects, and that all ethical requirements are considered. The committee also ensures that all research is carried out in accordance with the underlying ethical principles.

Identify the conflicting valuesDetermine the significant clues in the situation and identify the nature of the ethical problem.

1 Significant clues Obvious or probable signs that there is a conflict in values between:

the nurse’s personal and professional �

valuesthe nurse’s values and those of the client �

and his familythe nurse’s values and those of her �

colleagues


2 Conflicting valuesThe conflicting values that create unease either on the part of the client and his family or within the healthcare team.

Examine the ethical problem in light of the applicable regulatory framework

Take into account relevant professional ethics and legal considerations.

Decide on a strategyDetermine the actions to be taken to foster dialogue between the individuals concerned, in the client’s best interests.

Prioritize the values involved. �

Determine the actions and behaviours that �

sum up the appropriate conduct.

This conduct must be consistent with the priori-tized values and the regulatory framework applicable in the situation.

Explain the strategy. �

Ethics worksheet

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Situation 3.3 1

Norma is a nurse in the pediatric ward, and has been caring for a 10-year-old boy with acute lymphoblastic leukemia. Bruno is well known to the staff, as he has been receiving intensive chemotherapy treatments for several years. He has been fighting the disease bravely, but his situation has now been complicated by severe pneumonia, which is being treated with antibiotics. His parents are with him. They are well aware of the progress of leukemia and the complica-tions related to treatments.

Bruno is running a fever and having trouble breathing. A large mass in the mediastinum is interfering with his breathing. He has bone pain due to infil-tration of the bone marrow. The least shift or pressure on a bone makes him jump, because the pain is intolerable. The physician prescribed morphine: 0.05 to 0.2 mg/kg/dose sc q 4 h or q 2-4 h i.v. and a breakthrough dose of 0.1 mg/kg/dose sc prn. Norma notes that, just like her, some of her colleagues are not administering the breakthrough doses, because of Bruno’s respiratory state. They are worried the medication is exacerbating his respiratory depres-sion. Bruno is not eating and drinks a little. He says he is exhausted, and cries because of the pain. He often says, in his parents’ presence, that he does not want this chemotherapy any more, as it is making him sicker.

His parents talk about their worries concerning the refractory pain with Norma, and wonder about the chemotherapy treatments. They want their son’s suf-fering to be relieved as much as possible, and that he be made comfortable, in view of how his condition is progressing. Norma has to admit to herself that the child’s pain is starting to bother her as well.

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Identify the conflicting values1 Significant clues


2 Conflicting values

Situation 3.3 1Ethics worksheet

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Situation 3.3 2

Aline Tremblay, age 75, is suffering from Alzheimer’s dementia. The disease first appeared one year ago. She has been admitted to the geriatric ward following an abrupt deterioration in her condition. Her husband, Maurice Tremblay, who has been taking care of her at home, observed disturbing personality changes. She is manifesting unrealistic fears and often refuses to eat or take her medication. She is agitated and confused and lately has been falling at home. Mr. Tremblay tells Sylvia, the nurse, that their children feel that it would be safer to place their mother in a long-term care facility. He would prefer to obtain assistance to keep her at home. This difference of opinion is creating family tensions that are making life difficult for Mr. Tremblay and the caregivers. Mrs. Tremblay absolutely refuses to be separated from her husband; she flies into rages when he leaves at night.

Sylvia attends a meeting of the multidisciplinary team to discuss the client’s situation. She presents her assessment of the situation: Mrs. Tremblay is calmer when her husband is with her, and lately she has rarely refused to take her medication; she manages to eat when the staff gives her dishes one at a time and encourages her to eat; her husband participates in caring for her and is proving very helpful; he has read up on the disease, talks with groups of natural caregivers and, until now, has never called on home-care services. Sylvia feels that this support could make it easier to care for Mrs. Tremblay and improve the quality of their life together. A home-care nurse could help, if the couple agreed to this solution.

The client’s daughter has been delegated by her brothers and sisters to attend the meeting and explain their request that their mother be placed in a long-term care facility. She says they are concerned about their mother’s safety, and that she worries about her father’s health, at age 79. She explains that her brothers and sisters cannot offer more assistance to their parents, because they work and live far from the family home. Their father, she says, is not being realistic about the care required by their mother’s condition. If she came back to the house it would mean more worry and the need for extra help, which would have consequences on their families’ quality of life. They see this solution as a burden imposed on them.

Sylvia explains that the client is now being assessed to determine whether she is capable of consen ting to care. Mr. Tremblay is the mandatary designated by his wife if she is incapable. He has already told the nurse that he wants to respect his wife’s wishes to return home, and he feels that her quality of life will be better if she remains in familiar surroundings.

The physician confirms that Mrs. Tremblay’s cognitive disorder has worsened and that an adjust-ment in her medication could stabilize her condition. The daughter mentions that her mother often refuses to take her medication. She believes that her mother’s condition is bound to deteriorate and that her father will have to provide more and more care. She feels that it would be irresponsible on the part of the health professionals to encourage her father to keep his wife at home.

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2 Conflicting values

Situation 3.3 2Ethics worksheet

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ExERciSE 3.3


The nurses are not administering breakthrough doses of morphine, because they are worried about respiratory depression.

The parents want their son’s pain to be relieved as much as possible.

2 Conflicting valuesConflict between the nurses’ values and those of the parents regarding pain relief.

The parents give priority to their son’s quality of life through the optimal administration of analgesics.

The nurses give priority to respect for human life by not administering the breakthrough doses of analgesics, so as to avoid respiratory depression.


Right to information regarding treatments

Civil Code of Québec � , art. 10, 11, 14;C � ode of Ethics of Nurses, s. 40;Act respecting health services and social �

services, s. 8, 9, 12 (1).

The nurse’s role in relation to Bruno’s parents is to give them all the information they need to make an informed decision regarding his pain relief, in view of the possible side effects of morphine.

Respect for the values of the client and his parents

Charter of Human Rights and Freedoms � , s. 1;Code of Ethics of Nurses � , s. 30;Act respecting health services and social �

services, s. 3 (1), (2), (4).

Bruno and his parents have stated what they want, in view of how his condition is progres-sing. Respect for their values is essential to establishing a relationship of trust.


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Decide on a strategyPriority valueRespect for quality of life.

Appropriate actions and behaviourOptimal pain relief.

The nurse must give Bruno’s parents all the necessary explanations regarding the care pro-vided for their son, in particular the therapeutic effects of morphine and its side effects on the state of consciousness and breathing.

The nurse objectively assesses the child’s pain and tries to ease his pain properly, according to the medical prescription, by administering the required breakthrough doses.

She talks with her colleagues and the physician about ways of providing optimal pain relief, and palliative care appropriate to the child’s evolving condition. She adjusts the therapeutic nursing plan by giving instructions for optimal pain relief.

ExplanationBruno and his parents want optimal pain relief and palliative care appropriate to his evolving condition. They clearly state that his quality of life depends on the effective relief of his pain.

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Mr. Tremblay is the mandatary designated by his wife in case of incapacity.

He wants to respect her wishes by having her return home.

They both feel that her quality of life will be better if she remains in familiar surroundings.

The children want their mother to be placed in a long-term care facility, for her own safety and their father’s health.

They cannot offer additional assistance to their parents, because they work and live far from the family home.

2 Conflicting valuesConflict between the parents’ values and those of their children, concerning the right living environment for the client.

The parents give priority to Mrs. Tremblay’s quality of life by choosing to have her remain at home.

The children give priority to her safety, by choosing to have her placed in a long-term care facility.


Free and informed consentCivil Code of Québec � , art. 10, 11, 15, 16;Code of Ethics of Nurses � , s. 40, 41;Act respecting health services and social �

services, s. 8, 9, 10, 12 (2), (3).

It is primarily up to Mrs. Tremblay to consent to care and to decide whether to return home. A thorough assessment will determine whether she is capable of giving her consent. If not, it is her husband who represents her.

Respect for the couple’s valuesCharter of Human Rights and Freedoms � , s. 1;Code of Ethics of Nurses � , s. 30, 39;Act respecting health services and social �

services, s. 3 (1), (2), (3).

Mr. and Mrs. Tremblay have clearly expressed their wishes that they want her to return home. Respect for their values is essential to estab-lishing a relationship of trust.


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Decide on a strategyPriority valueRespect for quality of life.

Appropriate actions and behaviourSupport the husband and children concerning the decision as to whether Mrs. Tremblay should return home.

The nurse must inform Mrs. and Mr. Tremblay regarding her state of health, the different options concerning her return home, and the home-care services available to them.

The nurse must reassure the children, by explaining the home-care monitoring process and answering their questions about this new experience.

She must take into account the values of the client and her husband, who have chosen home care despite their children’s disagreement. She must also maintain a dialogue with the other family members, to better monitor develop-ments in the situation and support them as necessary.

The nurse must also make sure to indicate the appropriate follow-up in the therapeutic nursing plan.

ExplanationMrs. Tremblay, or Mr. Tremblay as her manda-tary if she is incapable, has the right to decide on the care required.

Conflict between family members is a reality that sometimes complicates a nurse’s interven-tions. However, Sylvia must always act in her client’s best interests, by not taking a position openly in the conflict between the father and his children.

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code of ethics

of nurses

appendix i

001-012_Annexe1_ALDO-EN_2851_F.indd 1 2/2/10 11:09:05 AM

Code of ethics of nurses Because we care about Quebecers’ health

“Our dream for Quebecers’ health is that everyone will have access to quality healthcare when they need it.”Lucie Tremblay

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Message froM The PresidenT

Working together to shape nursing care for tomorrowThis updated version of the Code of ethics of nurses more than ever reflects the dream we all share.

It is the most extensive update of the past decade. It will give Quebec nurses the means to adapt our everyday practice to Quebecers’ new healthcare needs, as it now covers the authorization to prescribe, psychotherapy practice, the assessment of mental disorders, and the use of assessment tools and social media.

Because we believe that nurses must receive the best possible training to keep pace with rapidly evolving scientific knowledge, health technology and social needs, this Code will be accompanied by the complementary training and communications necessary to master its contents and excel in the profession.

We consider our profession’s admirable reputation to be of the utmost importance, and we invite you to share any questions or concerns you may have as your updated Code of ethics comes into effect.

Lucie Tremblay, Nurse, MSc, AdmA, CHE

President

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Values of the nursing profession

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The shared values of our profession are based on its history and its culture. These fundamental values reflect the principles that guide nurses’ actions in their practice. All nurses adhere to these values and are committed to preserving the image and credibility of the profession.

Professional ethics are intended to regulate activities performed as part of one’s professional practice. They are inspired by the values that motivate professional conduct and are spelled out in professional codes of ethics. These values broadly define ideal practice, and include competence, a sense of responsibility, and social commitment. The Code of ethics helps define what this ideal means in everyday practice, by stipulating the duties and obligations arising from this shared ideal.

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The following values served as the pillars for the different divisions of the Code of ethics of nurses and helped define the resulting professional duties and obligations. The revision of the Code updates nurses’ professional duties and obligations, while reaffirming the values of the nursing profession.

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IntegrityIntegrity refers to honesty and truthfulness. It transcends all dimensions of the practice of the profession and is the cornerstone of nurses’ professional ethics.

Respect for the client This means both establishing and maintaining a relationship of trust, and recognizing the client’s uniqueness, right to privacy and decision-making autonomy, as expressed in his or her right to make choices and to be informed.

Professional autonomyThis relates to nurses’ ability to make objective and independent decisions in the client’s interest, and to be accountable and responsible for them.

Professional competenceCompetence refers to nurses’ responsibility to maintain and update their knowledge and skills and to take account of evidence-based data and best practices. It also means nurses’ ability to recognize and respect their limits in practising the profession.

Excellence in careExcellence in care is the raison d’être of the nursing profession, and reflects the importance accorded to human life. It means striving to ensure the well-being and security of clients of every age, at every stage in their lives, and is the ultimate goal of the nursing profession.

Professional collaboration This value reflects the importance of acting in partnership with other professionals and individuals involved, so as to ensure and optimize the quality and security of care and services for clients.

HumanityDemonstrating humanity in the provision of care means, in particular, showing generosity, tolerance and solidarity in dealings with others. It lets nurses show empathy and recognize others’ uniqueness.

These values were adopted by the OIIQ Board of Directors in December 2014.

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The Code of ethics of nurses

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The Code of ethics of nurses is a keystone of the Order’s professional legislation. The 2015 edition of this regulation is the most extensive update of the past decade. It is intended to adapt the Code to the new realities facing nurses, including the authorization to prescribe, psychotherapy practice, the assessment of mental disorders, and the use of assessment tools and social media. Many sections in the Code also deal with preserving professional secrecy and avoiding conflicts of interest.

The Code of ethics informs nurses of their duties and obligations toward the public, the clients and the profession.

Code of ethics of nurses (chapter I-8, s. 9)

– Professional Code (chapter C-26, s. 87)

– Nurses Act (chapter I-8, s. 3)

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CHAPTER I

DUTIES TOWARD THE PUBLIC, CLIENTS AND THE PROFESSION

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DIVISION I DUTIES INHERENT TO THE PRACTICE OF THE PROFESSION

§1. General provisions

1. A nurse shall come to the aid of anyone whose life is in peril, either personally or by calling for aid, by giving necessary and immediate assistance to that person, except in the event of danger to the nurse or a third party, or unless the nurse has another valid reason.

2. A nurse may not refuse to provide professional services to a person on the basis of race, colour, sex, pregnancy, sexual orientation, civil status, age, reli-gion, political convictions, language, ethnic or national extraction, social origin or condition, a handicap or the use of any means to palliate a handicap.

However, a nurse may, in the interest of the client, refer the client to another nurse.

In this Code, unless the context indicates otherwise, “client” means any person who receives care, treat-ment or other professional services.

3. A nurse shall not perform any act or behave in any manner that is contrary to what is generally admissible in the practice of the profession or that may tarnish the image of the profession.

3.1. A nurse shall take the necessary measures to ensure respect of the client’s dignity, freedom and integrity.

4. In connection with the care and treatment provided to a client, a nurse may not use or dispense products or methods that could be harmful to health or miracle treatments, nor may a nurse consult, collaborate with or refer a client to a person who uses or dispenses such products, methods or miracle treatments.

5. A nurse shall respect the right of the client to consult another nurse, another health professional or any other person of the client’s choice.

6. A nurse who is informed of the holding of an inquiry or who has been served with a complaint or who is informed of the holding of a professional inspection concerning her or him shall not harass, intimidate or threaten the person who requested the holding of the inquiry or any other person implicated in the events related to the inquiry or complaint, inspection.

7. A nurse shall take into account all of the fore-seeable consequences that her or his research and work will have for society and for human life, safety and health.

7.1. A nurse may not undertake or collaborate in any project involving research on humans that has not been approved by a research ethics committee formed or designated by the Minister of Health and Social Services or by another research ethics committee that respects recognized standards in matters of research ethics, particularly in regard to the composition of the committee and the methods by which it operates.

7.2. A nurse who undertakes or collaborates in research must advise the research ethics committee or another appropriate authority where the research or the manner in which it is being conducted appears not to conform to generally recognized scientific principles and ethical standards.

7.3. A nurse must refuse to collaborate or cease collaborating in any research activity where the risks to the health of subjects appear disproportionate having regard to the advantages that they stand to derive from the research or, if applicable, the advant-ages that they could derive from the usual care.

8. A nurse shall, to the extent that she or he is able, exchange knowledge with other nurses, nursing students and other persons engaged in the process of application preceding admission to the profession.

9. A nurse may not be released from personal civil liability in the practice of her or his profession.

In particular, a nurse is prohibited from inserting any clause directly or indirectly excluding such liab-ility, in whole or in part, or from being a party to a contract for professional services containing any such clause.

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§2. Integrity

10. A nurse shall fulfill her or his professional duties with integrity.

11. A nurse shall not abuse the trust of her or his client.

12. A nurse shall report any incident or accident that results from her or his intervention or omission.

The nurse shall not attempt to conceal such incident or accident.

When such an incident or accident has or could have consequences for the client’s health, the nurse shall promptly take the necessary measures to remedy, minimize or offset the consequences of the incident or accident.

13. A nurse shall not appropriate medications or other substances, including drugs, narcotic or anes-thetic preparations or any other property belonging to a person with whom she or he interacts in the practice of the profession.

14. A nurse shall not, in respect of a client’s record or any report, file, research record or docu-ment related to the profession:

(1) falsify same, in particular by altering any notes already entered therein or by inserting any notes under a false signature;

(2) fabricate any records, reports, files or documents;

(3) enter therein any false information;

(4) fail to enter therein any necessary information.

14.0.1. A nurse shall not issue to any person, or for any reason whatsoever, a false certificate or any written or oral information that she or he knows to be erroneous.

14.1. A nurse must not knowingly conceal from the persons or authorities concerned the negative findings of any research in which she or he has collaborated.

15. A nurse shall refrain from expressing or giving incomplete or groundless opinions or advice. To that end, the nurse shall attempt to acquire thorough knowledge of the facts before giving an opinion or advice.

15.1. When informing the public of a new method of care or a treatment which has not been suffi-ciently tested, a nurse must mention that fact and express the appropriate caution.

§3. Condition liable to impair the quality of care and services

16. In addition to the circumstances contem-plated by section 54 of the Professional Code (chapter C-26), a nurse shall refrain from practising her or his profession when she or he is in a state that is liable to impair the quality of care and services.

In particular, a nurse is in a state that is liable to impair the quality of care and services if she or he is under the influence of alcoholic beverages, drugs, hallucinogens, narcotic or anesthetic preparations or any other substance which may cause intoxica-tion, a diminution or disruption of the faculties or unconsciousness.

§4. Competence

17. A nurse shall act competently in fulfilling her or his professional duties. To that end, the nurse shall take into consideration the limits of her or his knowledge and skills.

18. A nurse shall practise her or his profession in accordance with generally accepted standards of practice and scientific principles. To that end, she or he shall update and develop her or his professional knowledge and skills.

19. If the client’s condition so requires, a nurse shall consult another nurse, another health profes-sional or another competent person or refer the client to one of such persons.

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§5. Professional independence and conflict of interest

20. A nurse shall subordinate her or his personal interest to that of her or his client.

21. A nurse shall safeguard her or his professional independence at all times. In particular, a nurse shall practise her or his profession with objectivity and disregard any intervention by a third party that could affect the performance of her or his profes-sional duties to the detriment of the client.

21.1. A nurse who organizes a training or inform-ation activity or who acts as a resource person as part of such an activity shall declare any direct or indirect interest in any commercial firm involved in holding the activity, to the participants and, if applicable, to any other person organizing such an activity.

21.2. A nurse who is authorized to issue prescrip-tions must, except in emergencies or in cases which are manifestly not serious, refrain from issuing a prescription to any person with whom she or he has a relationship likely to harm the quality of her or his practice, in particular her or his spouse or children.

22. A nurse shall not induce any person in insistent terms to make use of her or his professional services or to collaborate in any research.

23. A nurse shall avoid any situation in which she or he would be in conflict of interest. In particular, a nurse is in a conflict of interest situation:

(1) when the interests concerned are such that the nurse may be influenced to favour certain of them over those of her or his client or the nurse’s judgment and loyalty toward her or his client may be unfavourably affected;

(2) when the nurse receives, in addition to the remuneration to which she or he is entitled, any rebate, commission or benefit related to her or his professional activities or her or his research activities;

(3) when the nurse pays, offers to pay or undertakes to pay any rebate, commission or benefit related to her or his professional activities or her or his research activities.

24. In the event of a conflict of interest or the appearance of a conflict of interest, a nurse shall take reasonable measures to ensure that care, treat-ment or other professional services are provided by another nurse or another health professional or another person authorized by regulation to provide them, as applicable, unless the situation requires that the nurse administer or continue to administer them. In such circumstances, the client shall be advised of the situation, to the extent permitted by the circumstances.

24.1. A nurse who undertakes or collaborates in research must declare her or his interest and disclose any apparent or potential conflict of interest to the research ethics committee.

§6. Availability and diligence

25. In the practice of her or his profession, a nurse shall display due diligence and availability.

26. Where her or his specific knowledge and skills in a given area are needed in order to provide safe care, treatment or other professional services to a client, a nurse who is consulted by another nurse or another health professional shall provide the latter with her or his opinion and recommenda-tions within a reasonable time.

26.1. A nurse may not terminate the professional services provided to a client unless she or he has sound and reasonable grounds, in particular:

(1) when she or he is solicited by the client to commit an unlawful act or one contrary to this Code;

(2) when the client fails to respect the conditions agreed upon in the contract for professional services, including fees, and it is impossible to negotiate a reasonable agreement with the client to have them respected;

(3) when the nurse decides to reduce or terminate her or his practice.

27. Before ceasing to provide a client with profes-sional services, a nurse shall:

(1) give the client reasonable notice;

(2) take necessary measures to ensure that such termination of services is not detrimental to the client.

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DIVISION II RELATIONSHIP BETWEEN THE NURSE AND THE CLIENT

§1. Relationship of trust

28. A nurse shall seek to establish and maintain a relationship of trust with her or his client.

29. A nurse shall act respectfully toward the client and the client’s spouse, family and significant others.

30. A nurse shall respect, within the limits of what is generally admissible in the practice of the profes-sion, the client’s values and personal convictions.

§2. Provisions to preserve the secrecy of confidential information

31. A nurse shall abide by the rules set forth in the Professional Code (chapter C-26) in regard to the obligation to preserve the secrecy of confidential information that becomes known to her or him in the practice of her or his profession and the cases where she or he may be released from the obligation of secrecy.

31.1. A nurse who, in accordance with the third paragraph of section 60.4 of the Professional Code (chapter C-26), communicates information that is protected by professional secrecy, shall enter the following in the client’s record:

(1) the reasons supporting the decision to communicate the information, including the identity of the person who caused the nurse to communicate the information and the identity of the person or group of persons exposed to the danger;

(2) the elements of the communication including the date and time of the communication, the content of the communication, the mode of communication used and the identity of the person to whom the communication was made.

31.2. When a nurse provides professional services for a couple or a family, she or he shall preserve the professional secrecy of each member of the couple or family.

32. A nurse shall not disclose the fact that a person had recourse to her or his services, except if such disclosure is necessary in the interest of the client.

32.1. Before making an audio or video recording of an interview or activity or taking photographs of a client, a nurse shall obtain written authorization from the client or the client’s legal representative. This authorization must specify the intended use of the recording or photograph and the measures required for revoking the authorization.

32.2. When a nurse provides professional services to a group, she or he shall inform the members of the group of the possibility that aspects of a member’s or a third party’s private life may be disclosed.

In this context, the nurse shall give the group members instructions to enable them to respect the confidential nature of the information about other members’ or third parties’ private lives.

33. A nurse shall take reasonable measures to ensure that persons under her or his authority, in her or his employ or who are practising under her or his supervision do not disclose any confidential information concerning the client.

34. A nurse shall not make use of confidential information to the detriment of a client or with a view to obtaining, directly or indirectly, a benefit for herself or himself or for another person.

35. Whenever a nurse asks a client to disclose confidential information or whenever she or he permits such information to be disclosed to her or him, she or he shall ensure that the client knows the reasons therefore and the purpose for which the information will be used.

36. A nurse shall not hold or participate in indis-creet conversations, including on social networks, concerning a client and the services rendered to such client.

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§3. Prohibited behaviour

37. A nurse shall not use physical, verbal or psychological abuse against the client.

38. For the duration of the professional relation-ship, a nurse may not establish a personal friendship or an intimate, amorous or sexual relationship with the client.

For the purpose of determining the duration of the professional relationship, the nurse shall take into consideration, in particular, the client’s vulnerab-ility, the nature of the client’s health problem, the duration of the course of treatment and the like-lihood of the nurse having to provide care to the client again.

39. A nurse shall refrain from intervening in the personal affairs of her or his client on subjects not falling within her or his areas of professional expertise.

DIVISION III QUALITY OF CARE AND SERVICES

§1. Information and consent

40. A nurse shall provide her or his client with all the explanations necessary for the client’s compre-hension of the care, treatment or other professional services being provided to him or her by the nurse.

41. When a nurse is obliged to obtain a free and enlightened consent, she or he shall:

(1) provide the client with all the information required for that purpose;

(2) ensure that the client’s consent remains free and informed for the duration of the period during which she or he provides care, treat-ment or other professional services;

(3) respect the client’s right to revoke his or her consent at any time.

41.1. In connection with any research, a nurse must, in regard to each of the research subjects or their legal representative, ensure:

(1) that the subject is informed of the research project’s objectives and the manner in which it will be conducted, the advantages, risks or disadvantages for the subject, and the advantages provided by the usual care, if applicable;

(2) that free and enlightened consent is obtained in writing from the subject before he or she begins participating in the research or when there is any significant change in the research protocol;

(3) that the research subject is informed that his or her consent is revocable at any time.

§2. The therapeutic process

42. In the course of performing her or his duties, a nurse shall take reasonable measures to ensure the safety of clients, in particular by notifying the appropriate authorities.

43. A nurse who is providing care and treatment to a client may not abandon him or her without a serious reason.

44. A nurse shall not be negligent in the care and treatment provided to the client or to the research subject. In particular, a nurse shall:

(1) perform the assessment required by the client’s state of health;

(2) intervene promptly when the client’s state of health so requires;

(3) ensure the clinical monitoring and follow-up required by the client’s state of health;

(4) take reasonable action to ensure continuity of care and treatment.

44.1. A nurse who is authorized to issue prescriptions:

(1) shall not issue a prescription unless it is necessary for clinical purposes;

(2) when issuing a prescription, shall respect the client’s right to have it filled where and by whom the client wishes;

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(3) shall, when prescribing an examination or laboratory analysis, ensure the follow-up required by the client’s condition, unless she or he has ensured that another nurse, another professional or another authorized person can do so in her or his place.

45. A nurse shall not be negligent when adminis-tering or adjusting medication or other substances. In particular, when administering medication or other substances, a nurse shall have sufficient know-ledge of the medication and abide by the principles and methods applicable to its administration.

45.1. A nurse who uses assessment tools, in particular measurement tools, shall respect the standards of practice and scientific principles gener-ally recognized in that field for their use, adminis-tration and interpretation.

46. A nurse may not refuse to collaborate with health professionals engaged in providing care, treat-ment or services necessary for the client’s welfare.

DIVISION IV RELATIONS WITH PERSONS WITH WHOM THE NURSE INTERACTS IN THE PRACTICE OF THE PROFESSION

47. A nurse shall not intentionally mislead, betray the good faith of or engage in unfair practices toward a person with whom she or he interacts in the practice of the profession.

48. A nurse shall not intimidate or threaten or engage in any such behaviour toward a person with whom she or he interacts in the practice of the profession that is liable to compromise the quality of care or the client’s or public’s trust in the profession.

DIVISION V RELATIONS WITH THE ORDER

49. Unless she or he has serious grounds for refusing, a nurse shall participate or permit particip-ation in a disciplinary council, a review committee, a professional inspection committee, an arbitration of accounts or any other committee provided for by law, upon request of the Ordre des infirmières et infirmiers du Québec.

50. A nurse shall cooperate and respond as soon as possible to any request received from the secretary of the Order, a syndic of the Order, an expert or other person assisting the syndic, the professional inspection committee or a member, inspector or an expert of the committee.

50.1. A nurse shall respect any commitment she or he has made to the board of directors, the executive committee or the secretary of the Order, a syndic or the professional inspection committee.

51. Subject to any law or regulation to the contrary, a nurse may not authorize, assist or encourage any person who is not entered on the roll of the Order to perform an activity reserved to nurses.

Moreover, a nurse may not authorize, assist or encourage any person who is not entered on the roll of the Order to use the title of nurse or to allow others to believe she or he is a nurse.

DIVISION VI DETERMINATION AND PAYMENT OF FEES

52. A nurse shall require and accept fair and reasonable fees.

Fees are considered fair and reasonable if they are justified by the circumstances, in proportion to the professional services rendered and take into account, in particular,

(1) the nurse’s experience and specific expertise;

(2) the time spent in performing the professional service;

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(3) the complexity of the service; and

(4) the performance of unusual services or services requiring exceptional competence or speed.

The provisions set out in this division apply to the sale, by a nurse, of a vaccine that she or he admin-isters as part of a vaccination operation under the Public Health Act (chapter S-2.2) and that she or he has acquired in accordance with the Regulation respecting the terms and conditions for the sale of medications (chapter P-10, r. 12).

53. A nurse may not claim fees that are unwar-ranted, in particular for performing services that she or he knew or should have known were unnecessary or disproportionate to the client’s needs.

54. A nurse may not share her or his fees except with another nurse and then only to the extent that such division corresponds to a division of responsib-ilities and services.

55. A nurse shall provide her or his client with all the explanations required for the comprehension of the nurse’s statement of fees and of the terms and conditions of payment. In particular, she or he must indicate, in the statement of fees, the selling price of a vaccine covered under the third paragraph of section 52.

56. A nurse may require payment only for services rendered or products delivered, and shall inform her or his client in advance of the approx-imate and foreseeable cost of her or his professional services and inform the client promptly of any change in this respect.

After informing the client in advance, however, a nurse may charge reasonable cancellation fees for a missed appointment.

57. A nurse may collect interest on outstanding accounts only after having duly notified her or his client. The interest so charged shall be at a reason-able rate.

57.1. Before taking legal action, a nurse shall exhaust the other means at her or his disposal to obtain payment of her or his fees and other charges.

58. A nurse shall refrain from selling her or his accounts, except to another nurse or unless the client consents thereto.

DIVISION VII CONDITIONS AND PROCEDURES FOR THE EXERCISE OF THE CLIENT’S RIGHTS OF ACCESS AND CORRECTION OF INFORMATION CONTAINED IN RECORDS ESTABLISHED IN RESPECT OF HIM OR HER

§1. Provision applicable to nurses practising in the public sector

59. A nurse who practises her or his profession in a public body covered by the Act respecting Access to documents held by public bodies and the Protection of personal information (chapter A-2.1) or in a centre operated by an institution to which the Act respecting health services and social services (chapter S-4.2) or the Act respecting health services and social services for Cree Native persons (chapter S-5) applies shall abide by the rules relating to accessibility and correction of records set out in those Acts and facilitate their application.

A nurse who practises her or his profession in a public body covered by the Act respecting Access to documents held by public bodies and the Protection of personal information shall abide by the rules relating to accessibility and correction of records set out in these Acts and facilitate their application.

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§2. Provisions applicable to nurses practising in a sector other than the public sector in regard to the conditions and procedures for the exercise of the client’s right of access to information contained in records established in respect of him or her

59.1. A nurse who practises her or his profession in a sector other than the public sector referred to in section 59 shall abide by the rules relating to accessibility and correction of records set out in the Act respecting the Protection of personal informa-tion in the private sector (chapter P-39.1) and facil-itate their application.

60. A request covered by sections 61, 64 or 67 shall be delivered to the nurse’s professional domi-cile during regular working hours.

61. A nurse shall respond, with diligence and not later than 30 days following receipt thereof, to any written request made by her or his client to examine or obtain a copy of the information concerning the client in any record established in respect of the client.

62. Access to the information contained in a record shall be free of charge. However, a nurse may charge her or his client a reasonable fee for the reproduction, transcription or transmission of such information.

A nurse who intends to charge such fee shall, prior to reproducing, transcribing or transmitting the information, inform the client of the approximate amount that the client will be called upon to pay.

63. A nurse who temporarily refuses a client access to information contained in a record estab-lished in respect of the client because the disclosure of such information would be likely to cause serious harm to the client’s health shall notify the client accordingly in writing, with her or his grounds for refusing, and inform the client of his or her recourse.

The nurse shall determine when consultation of the record is possible and so inform the client.

63.1. A nurse who refuses to allow the client access to personal information concerning the client because its disclosure would be likely to reveal personal information about a third party or the existence of such information, and the disclosure would be likely to cause serious harm to the third party, unless the third party agrees to its communic-ation, or in an emergency in which the life, health or safety of the person concerned is endangered, shall notify the client accordingly in writing, with her or his grounds for refusing, and inform the client of his or her recourse.

§3. Provisions applicable to nurses practising in a sector other than the public sector in regard to the conditions and procedures for the exercise of the client’s right of correction of information contained in records established in respect of him or her

64. A nurse shall respond, with diligence and not later than 30 days following receipt thereof, to any written request made by her or his client to:

(1) cause to be corrected any information that is inaccurate, incomplete or ambiguous having regard for the purpose for which it was collected, contained in a document concerning the client included in any record established in respect of the client;

(2) cause to be deleted any information that is outdated or not justified by the object of the record established in respect of the client;

(3) file in the record established in respect of the client the written comments prepared by the client.

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65. A nurse who grants a request covered by section 64 shall issue to the client, free of charge, as the case may be:

(1) a copy of the document or portion thereof allowing the client to determine that the information has been corrected;

(2) an attestation that information has been deleted;

(3) an attestation that written comments have been filed in the record.

A nurse who refuses a request pursuant to section 64 shall, if the client so requests in writing, inform him or her of the reasons for this refusal, enter them in the record and inform the client of his or her recourses.

66. With the client’s consent, a nurse shall transmit, free of charge, to any person who had transmitted to the nurse the information contem-plated by section 64 as well as any person to whom such information was communicated within the six months preceding the correction, as the case may be:

(1) a copy of the corrected information;

(2) an attestation that information has been deleted;

(3) an attestation that written comments have been filed in the record.

§4. Obligation of a nurse practising in a sector other than the public sector to release documents to the client

67. A nurse shall, with diligence, release to a client who so requests any document entrusted by the client to the nurse and shall indicate in the client’s file, as appropriate, the reasons for the written request.

DIVISION VIII CONDITIONS, OBLIGATIONS AND PROHIBITIONS RELATING TO ADVERTISING

68. A nurse shall avoid all advertising likely to tarnish the image of the profession.

69. A nurse may not associate or permit the asso-ciation of her or his name with her or his professional title in an advertisement directed at the public for the purpose of promoting the sale of any medica-tion, medical product, product or method that could be harmful to health, or miracle treatment.

70. In addition to the obligations set forth in section 60.2 of the Professional Code (chapter C-26), a nurse who, in her or his advertising, claims to possess specific qualities or skills must be able to demonstrate them.

71. In her or his advertising, a nurse may not compare the quality of her or his services with the quality of the services provided or that may be provided by other nurses, and may not discredit or denigrate such services.

72. In her or his advertising, a nurse may not use or permit the use of an endorsement or statement of gratitude concerning her or him.

The preceding paragraph does not prevent a nurse from mentioning in her or his advertising an award for excellence or any other prize in recognition of a specific contribution or achievement related to the profession.

73. A nurse may not engage in or permit advert-ising that is likely to unduly influence persons who may be physically or emotionally vulnerable because of their age or state of health or the occurrence of a specific event.

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74. A nurse who advertises prices or fees for her or his professional services shall:

(1) establish fixed amounts;

(2) specify the services covered by these amounts;

(3) indicate whether or not disbursements are included in the amounts;

(4) indicate whether additional services may be required and specify the cost thereof.

The fixed amounts shall remain in effect for a minimum period of 90 days after the last broadcast or publication of the advertisement.

A nurse may nevertheless agree with a client on a price lower than the one broadcast or published.

75. Any advertisement by a nurse must be of such a nature as to adequately inform persons who have no particular knowledge of the area of expertise referred to in the advertisement.

76. A nurse shall keep a copy of every advertise-ment put out by her or him for a period of at least 5 years following the date on which the advertisement was last published or broadcast. The copy shall be given to a syndic of the Order or any investigator, inspector or member of the professional inspection committee who requests it.

77. A nurse who practises in partnership is solid-arily responsible with the other nurses for complying with the rules respecting advertising, unless the advertisement clearly indicates the names of those responsible therefor or unless the nurse demon-strates that the advertisement was published or broadcast without her or his knowledge or consent or in spite of the measures taken to ensure compli-ance with those rules.

DIVISION IX PROFESSIONS, TRADES, INDUSTRIES, BUSINESSES, OFFICES OR DUTIES INCOMPATIBLE WITH THE DIGNITY OR PRACTICE OF THE PROFESSION

78. A nurse may not sell, engage or participate for profit in any distribution of medications, equip-ment or products related to her or his professional activities, except in the following cases:

(1) where a sale of products or equipment is made in response to an immediate need of the client and is required for the care and treatment to be provided. In such case, the client shall be notified of any profit realized by the nurse upon the sale;

(2) where the nurse clearly distinguishes the place where care is provided from the place where the sale of products or equipment takes place and where her or his professional title is not associated with the commercial activities;

(3) where it concerns a vaccine covered under the third paragraph of section 52.

79. A nurse may not trade in products or methods that could be harmful to health, or miracle treatments.

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DIVISION X GRAPHIC SYMBOL OF THE ORDER

80. Where a nurse reproduces the graphic symbol of the Order for advertising purposes, she or he shall ensure that such reproduction is in conformity with the original held by the secretary of the Order.

81. Where a nurse uses the graphic symbol of the Order for advertising purposes elsewhere than on a business card, she or he shall include the following warning in the advertisement:

“This advertisement does not originate with the Ordre des infirmières et infirmiers du Québec and is binding on the author only.”

Where a nurse uses the graphic symbol of the Order for advertising purposes, including on a business card, she or he may not juxtapose thereto or other-wise use the name of the Order, except to indicate that she or he is a member thereof.

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CHAPTER II

FINAL PROVISIONS

82. This code replaces the Code of ethics of nurses (R.R.Q., 1981, c. I-8, r. 4).

This document is not the official version. The texts having the force of law are those published in the Gazette Officielle du Québec (O.C. 1513-2002, 2003 G.O.2, 64 ; O.C. 579-2005, 2005 G.O.2, 2056 ; O.C. 497-2008, 2008 G.O.2, 2046 ; O.C. 836-2015, 2015 G.O.2, 2744, which came into force on October 22, 2015).

Ordre des infirmières et infirmiers du Québec

Publication Sales 4200 Molson Montreal (Quebec) H1Y 4V4

Telehone : 514 935-2501 ou 1 800 363-6048 Fax : 514 935-3770

[email protected]

oiiq.org

Updated October 22, 2015

Legal Deposit

Bibliothèque et Archives Canada, 2015 Library and Archives Canada, 2015 ISBN 978-2-89229-668-6 (print) ISBN 978-2-89229-671-6 (PDF)

© Ordre des infirmières et infirmiers du Québec, 2015

All rights reserved

relevant sections of acts

and the regulation

appendix ii

1. Every human being has a right to life, and to personal security, inviolability and freedom.

He also possesses juridical personality.

2. Every human being whose life is in peril has a right to assistance.

Every person must come to the aid of anyone whose life is in peril, either personally or calling for aid, by giving him the necessary and immediate physical assistance, unless it involves danger to himself or a third person, or he has another valid reason.

3. Every person is the possessor of the fun-damental freedoms, including freedom of conscience, freedom of religion, freedom of opinion, freedom of expression, freedom of peaceful assembly and freedom of asso-ciation.

4. Every person has a right to the safeguard of his dignity, honour and reputation.

5. Every person has a right to respect for his private life.

9. Every person has a right to non-disclosure of confidential information.

No person bound to professional secrecy by law and no priest or other minister of religion may, even in judicial proceedings, disclose confidential information revealed to him by reason of his position or profes-sion, unless he is authorized to do so by the person who confided such information to him or by an express provision of law.

The tribunal must, ex officio, ensure that professional secrecy is respected.

10. Every person has a right to full and equal recognition and exercise of his human rights and freedoms, without distinction, exclusion or preference based on race, colour, sex, pregnancy, sexual orientation, civil status, age except as provided by law, religion, poli tical convictions, language, ethnic or national origin, social condition, a handicap or the use of any means to palliate a handicap.

Discrimination exists where such a distinc-tion, exclusion or preference has the effect of nullifying or impairing such right.

Charter of Human Rights and Freedoms

CQLR, c. C-12

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Civil Code of QuébecCQLR, c. CCQ

10. Every person is inviolable and is entitled to the integrity of his person.

Except in cases provided for by law, no one may interfere with his person without his free and enlightened consent.

11. No person may be made to undergo care of any nature, whether for examination, spec-imen taking, removal of tissue, treatment or any other act, except with his consent.

If the person concerned is incapable of giving or refusing his consent to care, a person authorized by law or by mandate given in anticipation of his incapacity may do so in his place.

13. Consent to medical care is not required in case of emergency if the life of the person is in danger or his integrity is threatened and his consent cannot be obtained in due time.

It is required, however, where the care is unusual or has become useless or where its consequences could be intolerable for the person.

14. Consent to care required by the state of health of a minor is given by the person having parental authority or by his tutor.

A minor 14 years of age or over, however, may give his consent alone to such care. If his state requires that he remain in a health or social services establishment for over 12hours, the person having parental authority or tutor shall be informed of that fact.

15. Where it is ascertained that a person of full age is incapable of giving consent to care required by his or her state of health and in the absence of advance medical directives, consent is given by his or her mandatary, tutor or curator. If the person of full age is not so represented, consent is given by his or her married, civil union or de facto spouse or, if the person has no spouse or his or her spouse

is prevented from giving consent, it is given by a close relative or a person who shows a special interest in the person of full age.

16. The authorization of the court is necessary where the person who may give consent to care required by the state of health of a minor or a person of full age who is inca-pable of giving his consent is prevented from doing so or, without justification, refuses to do so; it is also required where a person of full age who is incapable of giving his consent categorically refuses to receive care, except in the case of hygienic care or emergency.

The authorization of the court is necessary, furthermore, to cause a minor 14 years of age or over to undergo care he refuses, except in the case of emergency if his life is in danger or his integrity threatened, in which case the consent of the person having parental authority or the tutor is sufficient.

17. A minor 14 years of age or over may give his consent alone to care not required by the state of his health; however, the consent of the person having parental authority or of the tutor is required if the care entails a serious risk for the health of the minor and may cause him grave and permanent effects.

18. Where the person is under 14 years of age or is incapable of giving his consent, consent to care not required by his state of health is given by the person having parental authority or the mandatary, tutor or curator; the authorization of the court is also nec-essary if the care entails a serious risk for health or if it might cause grave and perma-nent effects.

26. No person may be confined in a health or social services institution for a psychia-tric assessment or following a psychiatric assessment concluding that confinement is necessary without his consent or without authorization by law or the court.

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Consent may be given by the person having parental authority or, in the case of a person of full age unable to express his wishes, by his mandatary, tutor or curator. Such consent may be given by the representative only if the person concerned does not object.

27. Where the court has serious reasons to believe that a person is a danger to himself or to others owing to his mental state, it may, on the application of a physician or an interested person and notwithstanding the absence of consent, order that he be confined temporarily in a health or social services institution for a psychiatric assessment. The court may also, where appropriate, autho-rize any other medical examination that is necessary in the circumstances. The applica-tion, if refused, may not be submitted again except where different facts are alleged.

If the danger is grave and immediate, the person may be placed under preventive confi nement, without the authorization of the court, as provided for in the Act respecting the protection of persons whose mental state presents a danger to them-selves or to others.

35. Every person has a right to the respect of his reputation and privacy.

No one may invade the privacy of a person without the consent of the person unless authorized by law.

37. Every person who establishes a file on another person shall have a serious and legitimate reason for doing so. He may gather only information which is relevant to the stated objective of the file, and may not, without the consent of the person concerned or authorization by law, communicate such information to third persons or use it for purposes that are inconsistent with the pur-poses for which the file was established. In addition, he may not, when establishing or using the file, otherwise invade the privacy or damage the reputation of the person concerned.

38. Except as otherwise provided by law, any person may, free of charge, examine and cause the rectification of a file kept on him by another person with a view to making a

decision in his regard or to informing a third person; he may also cause a copy of it to be made at reasonable cost. The information contained in the file shall be made acces-sible in an intelligible transcript.

39. A person keeping a file on a person may not deny him access to the information con-tained therein unless he has a serious and legitimate reason for doing so or unless the information is of a nature that may seriously prejudice a third person.

40. Every person may cause information which is contained in a file concerning him and which is inaccurate, incomplete or equivocal to be rectified; he may also cause obsolete information or information not justified by the purpose of the file to be deleted, or deposit his written comments in the file.

Notice of the rectification is given without delay to every person having received the information in the preceding six months and, where applicable, to the person who provided that information. The same rule applies to an application for rectification, if it is contested.

41. Where the law does not provide the condi-tions and modalities of exercise of the right of examination or rectification of a file, the court, upon application, determines them.

Similarly, if it becomes difficult to exercise those rights, the court, upon application, settles the difficulty.

1457. Every person has a duty to abide by the rules of conduct which lie upon him, according to the circumstances, usage or law, so as not to cause injury to another.

Where he is endowed with reason and fails in this duty, he is responsible for any injury he causes to another person by such fault and is liable to reparation for the injury, whether it be bodily, moral or material in nature.

He is also liable, in certain cases, to repara-tion for injury caused to another by the act or fault of another person or by the act of things in his custody.

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4. Every person is entitled to be informed of the existence of the health and social services and resources available in his community and of the conditions governing access to such services and resources.

5. Every person is entitled to receive, with continuity and in a personalized and safe manner, health services and social ser-vices which are scientifically, humanly and socially appropriate.

6. Every person is entitled to choose the pro-fessional or the institution from whom or which he wishes to receive health services or social services.

Nothing in this Act shall restrict the freedom of a professional to accept or refuse to treat a person.

7. Every person whose life or bodily integrity is endangered is entitled to receive the care required by his condition. Every institution shall, where requested, ensure that such care is provided.

8. Before giving his consent to care concerning him, every user of health services and social services is entitled to be informed of his state of health and welfare and to be acquainted with the various options open to him and the risks and consequences generally associated with each option.

The user is also entitled to be informed, as soon as possible, of any accident having occurred during the provision of services that has actual or potential consequences for the user’s state of health or welfare and of the measures taken to correct the conse-quences suffered, if any, or to prevent such an accident from recurring.

For the purposes of this section and sections 183.2, 233.1, 235.1 and 431 and unless the context indicates otherwise,

“accident” means an action or situation where a risk event occurs which has or could have consequences for the state of health or welfare of the user, a personnel member, a professional involved or a third person.

9. No person may be made to undergo care of any nature, whether for examination, specimen taking, treatment or any other intervention, except with his consent.

Consent to care or the authorization to pro-vide care shall be given or refused by the user or, as the case may be, his representative or the court, in the circumstances and manner provided for in articles 10 and following of the Civil Code.

10. Every user is entitled to participate in any deci-sion affecting his state of health or welfare.

He is entitled, in particular, to participate in the development of his intervention plan or individualized service plan where such plans are required under sections 102 and 103.

The same applies to any modification made to such plans.

12. The rights of any person which are recog-nized under this Act may be exercised by a representative.

The following persons are presumed to be representatives, according to the circums-tances and subject to the priorities provided for in the Civil Code:

1) the holder of parental authority of a user who is a minor or the user’s tutor;

Act respecting health services and social services

CQLR, c. S-4.2

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2) the curator, tutor, spouse or close rela-tive of a user of full age under legal incapacity;

3) an authorized person mandated by the incapable user of full age before his incapacity;

4) a person proving that he has a special interest in the user of full age under legal incapacity.

15. English-speaking persons are entitled to receive health services and social services in the English language, in keeping with the organizational structure and human, material and financial resources of the institutions providing such services and to the extent provided by an access program referred to in section 348.

19. The record of a user is confidential and no person may have access to it except with the consent of the user or the person qualified to give consent on his behalf. Information con-tained in a user’s record may, however, be communicated without the user’s consent […]

19.1. Consent to a request for access to a user’s record for study, teaching or research pur-poses must be in writing; in addition, it must be free and enlightened and given for specific purposes. Otherwise, it is without effect.

The consent is valid only for the time required for the attainment of the pur-poses for which it was granted or, in the case of a research project approved by an ethics committee, for the period deter-mined, where that is the case, by the ethics committee.

21. The holder of parental authority is entitled to have access to the record of a user who is a minor.

However, an institution shall refuse to give the holder of parental authority access to the record of a user who is a minor where

1) the user is under 14 years of age, an intervention within the meaning of section 2.3 of the Youth Protection Act (chapter P-34.1) has been made in his regard or a decision respecting him has been made under the said Act, and the institution, after consulting the director of youth protection, determines that communication of the record of the user to the holder of parental authority will or could be prejudicial to the health of the user;

2) the user is 14 years of age or over and, after being consulted by the institu-tion, refuses to allow his record to be commu nicated to the holder of parental authority and the institution determines that communication of the record of the user to the holder of parental authority will or could be prejudicial to the health of the user.

118.1. Force, isolation, mechanical means or chemicals may not be used to place a person under control in an installation maintained by an institution except to prevent the person from inflicting harm upon himself or others. The use of such means must be minimal and resorted to only exceptionally, and must be appropriate having regard to the person’s physical and mental state.

Any measure referred to in the first para-graph applied in respect of a person must be noted in detail in the person’s record. In particular, a description of the means used, the time during which they were used and a description of the behaviour which gave rise to the application or continued application of the measure must be recorded.

Every institution must adopt a procedure for the application of such measures that is consistent with ministerial orientations, make the procedure known to the users of the institution and evaluate the applica-tion of such measures annually.

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233.1. Any employee of an institution, any person practising in a centre operated by an insti-tution, any person undergoing training in such a centre or any person who, under a service contract, provides services to users on behalf of an institution must, as soon as possible after becoming aware of any incident or accident, report it to the executive director of the institution or to a person designated by the executive director. Such incidents or accidents shall

be reported in the form provided for such purposes, which shall be filed in the user’s record.

The executive director of the institution or the person designated by the executive director shall report, in non-nominative form, all reported incidents or accidents to the agency at agreed intervals or when-ever the agency so requires.

1. The provisions of this Act complement the provisions of the Civil Code concerning the confinement in a health and social services institution of persons whose mental state presents a danger to themselves or to others, and the provisions concerning the psychia-tric assessment carried out to determine the necessity for such confinement.

2. The psychiatric examination to which a person is required to submit by law or by a court decision must be carried out by a psychiatrist. However, if it is not possible to obtain the services of a psychiatrist in due time, the examination may be carried out by any other physician.

The person who carries out the examination may not be the spouse, a close relative or relative by marriage or a civil union or the representative of the person undergoing the examination or of the person who requested the examination.

6. Only an institution operating a local com-munity service centre equipped with the necessary facilities or a hospital centre may be required to place a person under preven-tive confinement or temporary confinement for psychiatric examination.

7. A physician practising in such an institu-tion may, notwithstanding the absence of consent, place a person under preventive

confinement for not more than 72 hours in a facility maintained by the institution, without the authorization of the court and prior to psychiatric examination, if he is of the opinion that the mental state of the person presents a grave and immediate danger to himself or to others.

The physician who places the person under confinement must immediately inform the director of professional services or, where there is no such director, the executive director of the institution.

On the expiry of the 72 hour period, the person must be released, unless a court has ordered an extension of the confinement for psychiatric assessment. However, if the seventy-two hour period ends on a Saturday or on a non-juridical day, if no judge having jurisdiction in the matter is able to act and if termination of confinement presents a danger, the confinement may be extended until the expiry of the next juridical day.

15. As soon as the person has been taken in charge by the institution, or as soon as he seems able to understand the information, the institution must inform him of the place where he is being confined, of the reasons for the confinement and of his right to contact his close relatives and an advocate immediately.

An Act respecting the protection of persons whose mental state presents a dangerto themselves or to others

CQLR, c. P-38.001

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38. For the purposes of this Act, the security or development of a child is considered to be in danger if the child is abandoned, neglected, subjected to psychological ill-treatment or sexual or physical abuse, or if the child has serious behavioural disturbances.[…]

39. Every professional who, by the very nature of his profession, provides care or any other form of assistance to children and who, in the practice of his profession, has reasonable grounds to believe that the security or deve-lopment of a child is or may be considered to be in danger within the meaning of sec-tion 38 or 38.1, must bring the situation to the attention of the director without delay. The same obligation is incumbent upon any

employee of an institution, any teacher, any person working in a childcare establishment or any policeman who, in the performance of his duties, has reasonable grounds to believe that the security or development of a child is or may be considered to be in danger within the meaning of the said provisions. […]

The first and second paragraphs apply even to those persons who are bound by profes-sional secrecy, except to an advocate who, in the practice of his profession, receives infor-mation concerning a situation described in section 38 or 38.1.

43. No person may be prosecuted for acts done in good faith under section 39 or 42.

Youth Protection Act CQLR, c. P-34.1

59. A public body shall not release personal information without the consent of the person concerned.

Notwithstanding the foregoing, a public body may release personal information without the consent of the person concerned in the following cases and strictly on the following conditions:[…]

4) to a person to whom the informa-tion must be disclosed because of the urgency of a situation that threatens the life, health or safety of the person concerned;

[…]

62. Every person qualified to receive personal information within a public body has access to personal information without the con-sent of the person concerned where such information is necessary for the discharge of his duties.[…]

67. A public body may, without the consent of the person concerned, release personal information to any person or body if the information is necessary for the applica-tion of an Act in Québec, whether or not the law explicitly provides for the release of the information.

An Act respecting Access to documents held by public bodies and the Protection of personal information

CQLR, c. A-2.1

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53. The record kept by a hospital centre shall include:

(1) report of outpatient services;

(2) medical observation, physical exami-nation, provisional diagnosis and dental examination;

(3) prescriptions;(3.1) a record of the preparation and

administering stages of medica-tion;

(4) progress notes by physicians, dentists, pharmacists and members of the clinical staff;

(5) report on the need for close treatment and on the capacity of the person to manage his property made under the Mental Beneficiaries Protection Act (R.S.Q., c. P-41) and reviews thereof;

(6) requests for and reports on consul-tation;

(7) requests for and reports on treatment;

(8) summary of interviews with profes-sionals;

(9) items used in arriving at a diagnosis or in prescribing a treatment, such as photographs, ultrasonic pictures, X-rays as well as parts of electrocardiograms and electroencephalograms and other relevant documents;

(10) reports of diagnostic examinations;

(11) the document required by section 52.1;

(12) the document attesting that the bene-ficiary’s consent was obtained for the care or services provided by the hospital centre;

(13) anaesthetic procedure;

(14) pre-operation diagnosis, nature of pro-posed surgery, operating procedure indicating the nature of the surgery, findings, operating techniques used and description of the parts removed;

(15) anatomical-pathological report and cytological report;

(16) reports of nosocomial infection;

(17) requests for transfer;

(18) reports on accidents to beneficiaries in any institution;

(19) the summary sheet, comprising the principal diagnosis, the order diagnoses and problems, complications, medical, surgical or obstetrical treatment, special examinations and the attestation of the attending physician confirming authenticity;

(20) a note of the beneficiary’s leaving;

(21) notice of discharge by the attending physician or dentist and a note that the beneficiary has left;

(22) beneficiary’s consent for the institution to take photographs, films or recordings of him;

(23) copy of the death certificate;

(24) report of autopsy.

Organization and Managementof Institutions Regulation

CQLR,c.S-5,r.5

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of Institutions Regulationof Institutions Regulation

54. The record kept by a social service centre shall include:

(1) a file index;

(2) a psychosocial assessment;

(3) the treatment plan and the periodic review reports;

(4) progress notes by members of the clinical staff;

(5) requests for and reports on consulta-tions;

(6) beneficiary’s consent for the institution to take photographs, films or recordings of him.

55. The record kept by a reception centre shall include:

(1) a file index;(1.1) a summary sheet;

(2) a medical assessment of the benefi-ciary;

(3) an assessment of the beneficiary’s autonomy;


(5) request for services;



(7) the treatment plan and the periodic review reports;


(9) report on the need for close treatment and on the capacity of the person to

manage his property made under the Mental Beneficiaries Protection Act (R.S.Q., c. P-41) and reviews thereof;

(10) requests for and reports on consulta-tion;

(11) the document attesting that the bene-ficiary’s consent was obtained for the care or services provided by the recep-tion centre;

(12) substituted;

(13) requests for transfer;

(14) reports on accidents to beneficiaries in any institution;

(15) report on confinement or isolation measures taken;

(16) beneficiary’s consent for the institution to take photographs, films or recordings of him;

(17) photographs, X-ray plates, electro-cardiograms and electroencepha-lograms, and other evidence used in arriving at a diagnosis or in prescribing a treatment;

(18) notice of discharge and a note that the beneficiary has left;

(19) copy of the death certificate.

56. The record kept by a local community service centre shall include:

(1) a file index;(1.1) a summary sheet;

(2) a medical or psychosocial assessment or an assessment of the beneficiary’s autonomy;


(4) request for services;

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(6) treatment plan and periodic review reports;


(8) consultation requests and reports;

(9) the document required by section 52.1;

(10) the document attesting that the bene-ficiary’s consent was obtained for the care or services provided by the local community service centre;

(11) reports of accidents to beneficiary in an institution;

(12) beneficiary’s consent to the institution’s taking of photographs, films or recordings of him;

(13) photographs, X-rays, electrocardiograms and electroencephalograms, and other evidence used in arriving at a diagnosis or in prescribing a treatment;

(14) anaesthetic procedures;

(15) pre-operation diagnosis, nature of pro-posed surgery, operating procedure indicating the nature of the surgery, findings, operating techniques used and description of the parts removed;

(16) a copy of the death certificate.

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