The practice of community health nursing in the Canadian Arctic has mostly been conducted by nurses from away who are recruited to the North. Recruitment is often aimed at nurses with a background in critical and emergency care so that they can be somewhat prepared for a new expanded primary health care role in the remote communities. This targeted consideration may address some of the clinical skills required for remote nurses but is short-sighted in terms of professionalism, cultural competency, and healthy workplace rapport. Nurses do not always know or understand the Northern context and, in particular, the worldviews and practices of Indigenous peoples of the north. Orientation to the community and the community health nurse role in a remote setting is often lacking. In adjusting to a change in scope of practice, personal and professional isolation and/or unhealthy behaviours acquired over years of practice and not so apparent in an urban setting, some nurses demonstrate incompetence, bullying and slander, and addiction. This chapter looks at professional conduct, as it is regulated in the Northwest Territories and Nunavut, in light of this context and seeks to identify professional values and practices along with socially just and culturally safe care.
Key Terms: professionalism, professional conduct, professional nursing and ethics
Despite the fact that professional responsibilities are engrained in: curricula across Canada, Standards of Nursing Practice, Scope of Practice, Competencies, Codes of Ethics (documents that are distributed to new graduates, registered nurses, and nurse practitioners), and continuing competency requirements are in place, unprofessional conduct is present in nursing practice across Canada, including the North. One could argue that this is influenced by many personal, contextual, systemic, and sociopolitical factors. As nurses become comfortable with their role and practice, some seasoned nurses become complacent about what is acceptable behaviour. For example, although nurses are well versed in the concept of confidentiality, when approached by a patient in the Northern store in a small community, the nurse must be vigilant about disclosure even though the community member may be openly sharing. The everyday socialness of the small community needs to be navigated astutely. Furthermore, there is a blurring of the personal and professional self in social media, as reported through research conducted with nurses in Italy and Britain (Levati, 2014). This, too, is also occurring in northern Canada, as local community members engage in Facebook and other forms of social media. At times, this might be as simple as texting a photo to a nursing colleague, who might then share it with unrelated others.
Regardless of these influences and the relatively small number of nurses being disciplined, it is alarming to the public and to the nursing profession when there is a poor outcome at the hands of a nurse, requiring a nurse’s license to be revoked, suspended, and/or conditions applied. It is also interesting to note that in these remotely populated territories, when a nurse is charged or being investigated for a criminal offense, particularly when there was a poor outcome for a patient in care, or if a criminal act has occurred, the story is often aired by the Canadian Broadcasting Corporation’s CBC North (Bird, 2016; Burke, 2015; CBC News, 2017). Radio, along with today’s use of Facebook, comprise primary sources of communication in northern communities, so any wrongdoings or alleged wrongdoings are known by all. This does not necessarily mean that a formal complaint has been lodged against the Registered Nursing Association of the Northwest Territories and Nunavut (RNANTNU) member, but it does mean there is considerable expression of public opinion.
It has been suggested that the incidence of unprofessional conduct for nurses is small in developed countries (Hudspeth, 2009). In fact, nurses have been said to be one of the most trusted health care providers in Canada (Huffington Post, 2017). In Canada, some nurses are concerned that the regulatory function of the College of Nursing has superseded a social justice mandate (Duncan, Thorn & Rodney, 2014). In spite of adequate undergraduate preparation to lead an exemplary professional nursing life, many nurses will hold individual beliefs and may argue that what happens in their off-duty time is not relevant to the nursing profession at all (Lipscomb, 2013).
In this chapter, we will highlight governance for registered nurses, remote nursing practice, the nature of complaints against registered nurses, and considerations about the professional conduct of registered nurses.
Governance and Self-regulation
The Nursing Profession Act for the Northwest Territories (NWT) was established in 1975 and has underwent amendments over the years; in 1999, the NWT divided into two territories: a much smaller NWT and the newly formed territory of Nunavut. In response, the Nursing Profession Act was amended to provide legislated direction to both territories; in 2002, the act was amended again to accommodate nurse practitioners (Government of the NWT, 2003).
RNANTNU is the self-regulating body for registered nurses and nurse practitioners who practice nursing in the two territories. Professional conduct is reviewed by the Professional Conduct Committee that consists of a Chairperson, Deputy Chairperson and the Director, Professional Conduct. This committee meets monthly to review new complaints, monitor current and past complaints, and close complaints. Section 32 of the Act defines unprofessional conduct in the following way1:
- (1) An act or omission of a nurse constitutes unprofessional conduct if a Board of Inquiry finds that the nurse (a) engaged in conduct that (i) demonstrates a lack of knowledge, skill or judgment in the practice of nursing, (ii) is detrimental to the best interests of the public, (iii) harms the standing of the nursing profession, (iv) contravenes this Act or the regulations, or (v) is prescribed by the bylaws as unprofessional conduct; or (b) provided nursing services when his or her capacity to provide those services, in accordance with accepted standards, was impaired by a disability or a condition, including an addiction or an illness (GNWT Justice, 2004, p. 29).
- (2) Examples of unprofessional conduct include: a) practice that fails to meet accepted standards; b) the abandonment of a patient in danger without first ensuring that the patient has obtained alternative medical or nursing services; c) verbal or physical abuse of a patient; d) irresponsible disclosure of confidential information about a patient; e) providing false or misleading information respecting birth, death, notice of disease, state of health, vaccination, course of treatment or any other matter relating to life or health; f) the impersonation of another member or health professional; g) obtaining registration or employment through misrepresentation or fraud; h) the failure, or refusal, without reasonable cause, to respond to an inquiry, or to comply with a demand for the production of documents, records, or other materials made by an investigator under sub-section 39(1) a conviction for a criminal offense, the nature of which could affect the practice of nursing.
There are many considerations for remediation when it is found that a complaint against a registered nurse is justified. The consequence of unprofessional conduct can vary from letters of discipline to conditions on the nurse’s license to suspension or removal from the registry. The process is often through a settlement agreement and may take the shape of medical care, counselling, coursework or reflective papers. These processes help to establish that the nurse is fit and competent to resume nursing practice. The magnitude of loss for a nurse experiencing discipline is recognized and careful and thorough consideration is given to resolve the matter in a just manner. Of utmost importance for the committee is protection of the people we serve, residents of the Northwest Territories and Nunavut.
Nursing Practice in Remote Settings in Canada
Literature about nursing practice in remote communities of Canada is increasing, particularly with two large national studies on rural and remote nursing (McLeod et al., 2017). Nurses who are employed in remote settings are most often the only health care practitioners providing primary health care, including maternal and child health, primary care, emergency care, monitoring and surveillance of chronic conditions, and close involvement with education, housing and sanitation departments; are working in professional isolation; and have described feeling like outsiders in these communities (Tarlier, Browne & Johnson, 2007). Recruitment and retention of nurses in remote Canada is problematic with staffing instabilities contributing to turnover, short stay, and agency nurses (Kulig, Kilpatrick, Moffitt & Zimmer, 2015). Furthermore, the practice of northern nurses in primary settings has been critiqued and described as colonizing nursing practice (Rahaman, Holmes & Chartrand, 2007). It is suggested that the colonized nature and power imbalances between nurses and their clients leads to fragmentation of care.
Nature of Complaints against Nurses
The Professional Conduct Committee of the nursing association receives complaints against nurses. Statistical data in terms of the number of complaints and the type of complaint are established, tabled, and monitored yearly. This dataset is used in the following section.
The nature of the complaints against nurses working in the Northwest Territories and Nunavut vary, and include addiction to alcohol and/or drugs, breaches of confidential patient information, and care and practice that does not meet acceptable clinical or professional standards. The incidence of nurses contributing to toxic work environments2 is on the rise and in clear violation of Standards of Practice and the Code of Ethics for Registered Nurses and Registered Nurse Practitioners.
Inappropriate and unprofessional use of social media3 is another area of concern related to professional conduct for nurses coming to work in northern Canada. Many of the nurses coming to work in the various community health centres scattered across the North are excited for the challenge, as well as the experience of seeing and living in the North. When sharing on social media, all nurses need to be cognizant of the scope of distribution of information in electronic form, the fact that many postings to social media are permanent, and posting anonymously does not protect against the possible consequences of a breach of confidentiality.
Documentation4 is an integral part of nursing care and unfortunately, the lack of accurate and complete documentation, is often the basis for a complaint of poor professional practice. In the community health centres in both Nunavut and the Northwest Territories, SOAP format is used for documentation. Many nurses coming to work in the North in the expanded practice role are not familiar with SOAP documentation. The Community Health Nurse (CHN) will receive a brief orientation to the format; however, audits of the charts and the new CHN’s documentation may not happen early enough to give guidance and provide feedback. Even today, the thinking continues, “If it isn’t charted/documented it hasn’t been done – the care was not given.” (personal communication, Director Professional Conduct, February 1, 2018)
Another common complaint is poor or lack of sound clinical judgement when caring for clients. This is directly linked to the nurse’s failure to adhere to established policies, guidelines, and government directives, and the non-availability of good clinical orientation and mentorship, which in turn may be related to lack of staffing and the fact that nursing staff for the majority of health centres typically number from two to five nurses in total. Because of the instability of the nursing workforce in Nunavut, in particular, and the North in general, the nurses may not be fully informed regarding the use of these policies, guidelines, and directives.
Clinical judgement5 does appear in complaints to the Professional Conduct Committee. Community health nurses working in an expanded advanced practice role need to demonstrate they have sound clinical judgement, are strong critical thinkers, and are clinically competent to perform this independent and critical nursing role. These attributes are unlikely to have been acquired by a nurse who has minimal post-graduate experience and more likely to be subsumed in a nurse whose prime motivator for working in the North is the enhanced salary scales and tax incentives.
Vulnerability is a part of every nurse’s practice in terms of “making an error, breaching or failing to meet a standard, and proneness to being reported to a nurse regulatory authority.” (Pugh, 2011, p. 21). Pugh (2011), in a grounded theory study on 21 Australian nurses alleged with unprofessional conduct, identified personal and professional vulnerability in their everyday contexts. He described two kinds of vulnerability – one related to poor decision making related to below standard practice and the other linked to motivations in the workplace to report nurses such as, whistleblowing or a duty to report. We suggest that this vulnerability escalates in a remote setting where nursing practice is described as being in a fishbowl. Nurses and their nursing practice are central to what is happening in the community. The way a nurse acts or does not act in both her/his personal and professional life is open for scrutiny.
As a self-regulating profession, nursing relies upon provincial and territorial Associations to fulfil its mandatory obligations to protect the public from unsafe nursing practice. The Professional Conduct Committee of RNANTNU accepts and investigates complaints and provides remedial action where needed. RNANTNU has a high proportion of its members practicing as community health nurses with an expanded scope of practice, mostly in very remote and isolated settings, where oversight of practice is minimal.
It is important to acknowledge that cultural competence is essential for nurses working with Indigenous peoples. The governments of both Nunavut and Northwest Territories recognize the importance for new nurses to realize the history of colonization and the devastation this had and continues to have on Indigenous people. Both governments have developed a guide to understanding the history and impact of Residential School (GNWT, GN & Legacy of Hope Foundation, 2013). Since the territories have a short-term and revolving workforce in remote communities, it is vital that a targeted effort is directed towards nurses working in remote communities to acquire and understand this history, the effects it has had on the health of individuals and communities, and move forward with strategies at all levels for reconciliation. Hines-Martin and Nash (2017) have recommended key concepts to combat social disparities : social justice, social determinants of health, interprofessional, practice and community engagement. These authors suggest that this will lead to improved health outcomes. For interprofessional practice and community engagement to be realized, there needs to be a more permanent workforce to build relationships with individuals and communities and get out of some of the nursing silos that exist. When these steps are taken, professionalism can be achieved.
It is incumbent upon every member of the Association to be aware of not only their own scope of practice and individual competencies but also policies and statements which govern the practice of nursing. These would include at a minimum scope of practice, standards of practice, code of ethics all to be found on the RNANTNU website. Similar documents are available on all other provincial/territorial association and CNA and CNPS websites. In order to practice nursing competently all nurses should be very familiar with the contents of such documents and revisit them frequently throughout their nursing career.
- The act is quoted verbatim in this chapter to give the reader an opportunity to consider the legislation.
- Furthermore, workplace bullying is defined as “harassing, offending, socially excluding someone or negatively affecting someone’s work (Lutgen-Sandvik, Tracy, & Alberts, 2007; Waschgler, Ruiz – Hernandez, Llor -Esteban & Jimenez -Barbero, 2013). This kind of bullying, when carried out in the health care sector by a colleague is known as lateral or horizontal workplace bullying/violence and when carried out by a superior is known as vertical workplace/bullying/violence (Waschgler et al., 2013). Other terms used to describe this behaviour in literature include, “nurses eating their young”, verbal abuse, disruptive behaviour and incivility” (Sauer, 2012, 1). See the Canadian Nursing Student Association’s Position Statement on Creating and Empowering Environment for Nursing Students to Eliminate Bullying in the Nursing Profession.
- The Registered Nurses Association of the Northwest Territories and Nunavut position statement on Social Media identifies benefits and risks to the professional registered nurse and registered nurse practitioner regarding the use of various online and mobile social media tools. The benefits identified include, “Using social media allows for rapid, convenient, and efficient exchange of information. Social media promotes education, research, and evidence based practice by providing opportunities for health care professionals to network, collaborate, and disseminate knowledge. Social media provides a platform for nurses to engage in advocacy and promote the nursing profession” (RNANT/NU, 2015). The risks associated with the use of social media include, “RNs and NPs must be aware of the professional and legal risks associated with the inappropriate use of social media. Such risks include: confidentiality and privacy breaches, violation of professional boundaries, damage to professional integrity, defamation of character (nurse, client, and / or organization), public mistrust, and employment consequences. Violations may result in disciplinary action by RNANT/NU leading to loss or suspension of nursing license, and /or civil or criminal proceedings by individuals or organizations” (RNANT/NU, 2015).
- Documentation is a crucial component of safe, ethical, and effective nursing practice, irrespective of the context of practice or whether the documentation is paper – based or electronic. Documentation is defined as any written or electronic recoding that describes the status of a client or the client care provided (Lyeria & Barry, 2014). RNANT/NU Documentation Guidelines states, “Documentation establishes accountability, promotes quality nursing care, facilitates communication between health care providers and conveys the contribution of nursing to health care. Documentation is neither separate from care nor optional. Documentation is a vital part of nursing practice” (RNANT/NU, 2015, p. 4).
- Sound clinical judgement is directly related to the nurse’s ability to think critically. “Higher cognitive skills are essential competencies for nurses joining the technologically and increasingly complex health care environment to provide safe and effective nursing care. Educators and clinical facilitators have recognized that newly qualified nurses do not meet the expectations for entry level clinical judgement and are held accountable for finding adequate learning experiences as preparation for such practice demands”. (van Graan, Williams, & Koen, 2016, p. 1) The American Association of Colleges of Nurses’ definition of critical thinking states, “Critical thinking underlies independent and interdependent decision making. Critical thinking includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application and creativity”.). Benner, Hughes, and Sutphen (2008) also indicate, “The growing body of research, patient acuity and complexity of care demand higher – order thinking skills. Critical thinking involves the application of knowledge and experience to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes.” (p. 2)
Canadian Nursing Association (CNA) Code of Ethics https://cna-aiic.ca/html/en/Code-of-Ethics-2017-Edition/files/assets/basic-html/page-1.html#
Registered Nurses Association of the Northwest Territories and Nunavut (RNANT/NU) Position Statement on Social Media https://www.rnantnu.ca/sites/default/files/Position%20Statement%20Social%20Media%20Statement.pdf
Canadian Nurses Protective Society (CNPS) InfoLaw Quality Documentation https://www.cnps.ca/index.php?page=85
Canadian Nurses Protective Society (CNPS) Infolaw Social Media https://cnps.ca/socialmedia
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