Resolving Professional Practice IssuesCRNNS Continuing Competence Education

WORKBOOK FOR DI R EC T C A R E

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IntroductionWelcome to the College of Registered Nurses of Nova Scotia (CRNNS) workbook on “Resolving Professional Practice Issues (PPI)”. To get started, please review the introductory video (crnns.ca/registration/ccp/mandatory-education-area) and complete the pre-quiz (crnns.ca/registration/ccp/mandatory-education-area/step-1-pre-quiz) by clicking on these links before beginning the workbook if you haven’t already done so.

The workbook is one of three available options for completing the education component of the continuing competence program. This workbook contains the same information as the live webinar and recorded presentation found on the mandatory education webpage (crnns.ca/registration/ccp/mandatory-education-area). You are not required to complete all three options.

After completing the workbook, you will have:

• Reviewed the six step framework that can be used to address any PPI

• The information needed to be successful at the post-quiz

After completing the workbook, you must successfully complete the post-quiz, one component to obtain a 2018 active-practising license. The quiz consist of 10 multiple choice or true or false questions. Feel free to save this workbook to your desktop or print it for further reference by following the instructions on the webpage (crnns.ca/registration/ccp/mandatory-education-area/step-2-education/workbook). The workbook is designed to be completed on your computer to enable you easy access to the resource links included.

Professional practice issues happen in all practice settings. Although the examples in this workbook may not represent your specific practice area, the six step framework can be applied to a PPI in any setting.

One resource that could be helpful as you complete the workbook and the post-quiz is the Resolving Professional Practice Issues: A Toolkit for Nurses (crnns.ca/supporting-your-practice/resolving-professional-practice-issues).

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IDENTIFY THE PROFESSIONAL PRACTICE ISSUE

EXPLORE THE ISSUE AND DEFINE HOW CLIENT CARE / SERVICE IS AFFECTED

IDENTIFYRESOURCES

TAKE ACTION DOCUMENT EVALUATE

1. 2. 3. 4. 5. 6.

Nurses as Self-Regulated ProfessionalsOne of the goals of nursing self-regulation is to ensure that the public receives safe, compassionate, competent and ethical care from registered nurses (RNs) and nurse practitioners (NPs). This is why CRNNS’ mandate is focused on public protection. This is done by supporting RNs and NPs to practice in accordance with their standards of practice.

The responsibility for nursing self-regulation is a shared one, between CRNNS and individual nurses. As self-regulated professionals, nurses are legally and ethically required to take immediate action if they notice a PPI or something that places a client at risk.

This requirement is reflected in our Standards of Practice for Registered Nurses (crnns.ca/wp-content/uploads/2015/02/RNStandards.pdf) and Nurse Practitioner Standards of Practice (crnns.ca/wp-content/uploads/2015/02/NPStandards2014-WEB.pdf). One way individual nurses regulate their nursing practice is by ensuring they meet their standards of practice. Meeting these standards is a foundational principle of self-regulation and one way that we as a profession maintain the public’s trust in our ability to self-regulate. For more information on self-regulation, check out the document called What Self-Regulation Means to You (crnns.ca/wp-content/uploads/2016/01/What-Self-Regulation-Means-to-You-Fact-Sheet.pdf).

Professional Practice IssuesMany PPIs that nurses encounter can be effectively addressed fairly quickly using strategies such as effective communication, collaboration, or by working through the issue using a problem solving approach. This workbook and the Professional Practice Issues Toolkit have been developed to support nurses when working through a PPI that is not easily resolved and/or requires you to work with management.

Every nurse, regardless of where they practice, is a leader. Resolving a PPI requires you to act in this leadership role. We define leadership as using your actions to guide or influence others toward a shared goal. Nursing leadership is about leading in your nursing practice and is demonstrated by how you carry out your nursing role and/or interact, collaborate and influence others.

The Resolving Professional Practice Issues: A Toolkit for Nurses (crnns.ca/supporting-your-practice/resolving-professional-practice-issues), outlines a six step framework to use when resolving a PPI. This workbook will take you through each of these steps. The six steps are:

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STEP ONE

In order to identify a PPI, we first need to define what a PPI is. A PPI is an issue or situation that:

• Places your client(s) at risk; and/or

• Affects your ability as an RN or NP to provide care or services consistent with your Standards of Practice, the CNA Code of Ethics, or agency policies or procedures.

EXERCISE 1: HAVE YOU FACED A PPI RECENTLY?

Take a few minutes to think about an issue you have faced at work over the past couple of weeks. Consider these questions to determine if it was a PPI.

Did your situation:• Present a risk to clients? If so, how?

• Make it difficult to practise according to the Standards of Practice for RNs/NP Standards of Practice, the CNA Code of Ethics (crnns.ca/wp-content/uploads/2015/02/code-of-ethics-for-registered-nurses.pdf), Acts or other legislation?

• Conflict with your organization’s standards, guidelines, and/or policies?

Answer here - Was your situation a PPI? Why or why not?

STEP TWO

It is important to take time to fully explore a PPI to ensure you really understand it and are aware of all factors that have contributed and influenced the issue. This enables you to more accurately identify who is involved and impacted, the root causes and to gather helpful information when communicating the issue to others or deciding how to best address the PPI.

One way to explore an issue is by using reflection. Reflection is a powerful tool that can help you see a PPI more objectively by looking at it from different

perspectives. This helps to provide additional insight and a deeper understanding. Reflection can be achieved by working through a set of questions specifically designed to help you explore the issue and can be especially effective when completed with others involved, such as co-workers, clients or managers, by having them respond to the same set of questions.

IDENTIFY THE PROFESSIONAL PRACTICE ISSUE

1. 2.

EXPLORE THE ISSUE AND DEFINE HOW CLIENT CARE / SERVICE IS AFFECTED

2. 3.

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Here are some questions to help you reflect on and explore a PPI. When you are reflecting on a specific issue, answer these questions as specifically as possible.

1. What makes this a PPI? For example, how does this issue:

• Place clients at risk?

• Affect your ability to practise according to your nursing standards of practice and code of ethics?

• Prevent you from following agency policies and procedures?

2. What factors have contributed to the PPI?

3. Do you have the knowledge and skill to address the PPI? If not, who does?

4. Who is affected by the PPI and what are their perspectives?

5. Do your organizational policies, procedures, or guidelines contribute to this issue?

6. Is this a recurring PPI? And if so, why is it recurring?

By taking the time to identify underlying causes by looking below the surface you may see things not immediately obvious.

EXERCISE 2: EXPLORING THE ISSUE

What do you think could be potential causes or contributing factors for a PPI in your nursing practice?

Some contributing factors that you may have identified could have included: communication, competency, documentation, legal/ethical, resources, policies and procedures – existing or lacking, responsibility/accountability, standards of nursing practice or others.

There can be more than one contributing factor for a PPI. Identifying these factors makes it easier to determine the underlying cause of the issue. When you are able to address the underlying cause, you become more effective at resolving the issue.

As part of step two, use the information gathered to develop a detailed description. By developing this description, you help ensure the issue is: clear in your mind, has been fully explored, and you have a means to clearly communicate it to others.

In the PPI description, be sure to include:

• Specific information such as date, time, place, persons involved

• An explanation of how the issue impacts on the client, your practice and/or the team

• Any contributing factors.

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EXERCISE 3: SCENARIO

Let’s explore an example now. Meet Brad and Adele.

One of Brad’s clients has a stat order for an NG tube due to a bowel obstruction. Brad has never cared for a client requiring an NG tube before. His client is in a great deal of distress so Brad quickly scans the procedure and starts to assemble the supplies he needs to insert the tube.

Adele, the team leader, notices Brad seems unsure about his task and inquires if he has inserted an NG tube before. Brad admits he has not. Adele expresses her concern to Brad that he did not attempt to contact the nurse educator or ask a co-worker for support, placing the client’s safety at risk. Adele quickly inserts the NG tube.

a. Is this a PPI? Why or why not? Add your thoughts below. Remember to consider these questions when deciding: does this situation present a risk to clients, conflict with organization’s standards, guidelines, and/or policies, and/or make it difficult to practice according to your standards of practice, the CNA Code of Ethics, Acts or other legislation?

Adele identified this situation as a PPI because Brad did not follow his agency procedure by seeking appropriate support prior to attempting the skill. If he had carried out the procedure, he could have placed the client at risk and violated his standards of practice. In addition, Brad’s actions may cause Adele to start to question whether or not he seeks support for other procedures when he needs to.

b. Now let’s explore this issue using the reflection questions we discussed earlier, including: what makes this a PPI? What are contributing factors? Do you have the needed knowledge and skill needed to address it? What are the perspectives of others affected? Do policies, procedures, or guidelines contribute? Does the issue recur? If so, why?

Add your conclusions below after considering these reflection questions.

Did you conclude that Adele felt Brad placed his client at potential risk by deciding to go ahead with the procedure and that he would have been in violation of his standards if he had proceeded? He also did not follow agency procedure as he did not attempt to contact the educator or a co-worker to support him with the task.

Contributing factors included the acute need of the client, Brad not having preformed the skill previously, the decision Brad made to attempt to insert the tube, and Adele deciding to question Brad based on her observations. As for other’s perspectives – Adele recognized the risk, communicated her concerns and provided care to the client to meet the client’s acute needs.

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This is the statement that Adele prepared to ensure she was able to objectively and clearly discuss this PPI with Brad and her manager.

On Sept. 18, 2017, at 0815 hrs. I noticed Brad preparing to insert an NG tube for a client in distress. Brad appeared unsure so I questioned if he had performed this skill before. He had not. The factors that contributed to this PPI were the acute need of the client and Brad’s decision to attempt to insert the NG tube without the appropriate support. This situation created a potential safety risk for the client. This PPI affected myself, the client, and Brad. I was able to insert the NG tube right away, addressing the client’s immediate care need but I feel steps need to be taken to ensure Brad obtains the knowledge and skills needed to perform this task in the future.

c. Review Adele’s statement and decide if she included everything in her PPI statement. For example did she describe the issue, identify the contributing factors, and describe the impact on client and/or their nursing practice? We feel she did.

REVIEW

Good work! Here are some questions to review the content so far.

1. As self-regulated professionals striving to provide optimal nursing care, RNs and NPs are legally and ethically obligated to recognize and attempt to resolve professional practice issues as they arise in practice.

True or False

2. One thing that indicates you are facing a professional practice issue is that the situation places your client(s) at risk.

True or False

3. Developing a clear PPI statement is an important step because this helps to ensure you can clearly communicate the PPI to others.

True or False

4. What information would you gather when exploring (reflecting on) a professional practice issue?

For the first three review questions, the answers are all true and the response to the fourth question can be found on page five.

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STEP THREE

There are various resources that can support you or provide information you may need to resolve a PPI.

The resources you use will be determined by the issue you are facing, the people involved and what is available to you.

Here are some examples of resources that could be helpful.

Resources internal to your organization:

• Co-workers, managers, mentors, agency policies and procedures, etc.

Supports external to the organization:

• Practice Consultant at CRNNS, Canadian Nurses Protect Society (CNPS), research articles, etc.

Resource documents:

• CNA Code of Ethics, CRNNS documents, policies and procedures.

EXERCISE 4: SCENARIO

Let’s meet Susie, an RN working in a Long Term Care Facility.

Susie is a RN who works at a LTC facility. She has just learned a new client will be moving in this week who has a supra pubic catheter. The RNs have not provided this care before. Education and policies to support the care are under development but may not be completed before the client moves in to the facility.

Susie does not feel she has the knowledge and skills to safely carry out this care. She also has concerns about beginning before the policies are in place.

First of all, let’s take a second to think about what makes this situation a PPI.

It is a PPI because of the risk to client safety caused by the lack of policy and training prior to the RNs being expected to perform the task.

Now, brainstorm some resources that Susie could access to help her resolve this PPI.

Possible resources could include the Standards of Practice for Registered Nurses, Code of Ethics, her manager, connecting with other LTC facilities to see what they do, or a practice consultant at CRNNS, to name a few.

IDENTIFYRESOURCES

3. 4.

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STEP FOUR

PPI’s can be complicated to address. When this is the case, addressing the issue effectively will require careful thought and planning prior to taking action.

When a planned approach is required, you can follow these steps:

1. Brainstorm possible solutions to resolve the PPI.2. Determine the potential positive and negative outcomes for each solution. 3. Decide which solution(s) could be the best approach.4. Develop a plan outlining the actions you will take and when.

Adele, from the scenario we explored at step 2 of the workbook, used this approach to identify the steps needed to ensure Brad developed the knowledge and skills he required for his practice. She started by discussing the situation with Brad and the manager. Together, after exploring various solutions, they decided Brad would work with the unit educator and develop a plan to obtain any additional skills he required. The manager also had a discussion with Brad reminding him of the importance of meeting his standards of practice.

When exploring your options, keep in mind the goal is to minimize the effects a PPI can have on care. You may even be able to intervene early enough to prevent a PPI from occurring. Despite our best efforts though, there can be times when factors outside of our control result in a PPI.

EXERCISE 5

This is a list of actions nurses could take, some that could help prevent or minimize the impact of a PPI, and a few that likely wouldn’t be so helpful. Review the list and identify the ones that likely would not help to prevent or minimize a PPI by underlining them.1. Communicate in a professional manner - focus on issue 2. Familiarize self on professional standards and code of ethics3. Keep up to date on agency policies and practices4. Wait for your manager to address the PPI 5. Take quick action and address issues as they arise 6. Discuss issue repeatedly with coworkers without taking action7. Support a “no blame” and supportive workplace culture8. Wait for someone else to respond to the issue9. Take steps to strengthen collaboration and team work10. Keep everyone involved11. Ignore the issue and hope it resolves itself12. Stay focused on resolving the issue and on what is in the best interest of the client

TAKE ACTION

4.

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It is helpful to remind ourselves and the team to keep #12 in the forefront at all times as you work through a PPI to keep everyone focused on the common goal. Did you identify numbers 4, 6, 8, and 11 as not being helpful when trying to address a PPI?

Throughout the process of resolving a PPI, remember to:1. Let your manager know about any PPI you encounter so they are informed and can provide support as

required, and2. Adopt a solutions- focused approach by exploring how the issue could be resolved and by identifying what

you can do to support this process.

Notifying Your ManagerIt is good practice to make your manager aware of any PPIs. If, for any reason, your attempts to resolve the PPI on your own or with the team are unsuccessful or the PPI results in a risk to client safety, your manager needs to be notified immediately. During these discussions, be sure to share:

• Your PPI description • Other relevant objective information • How the issue impacts on the client and/or your practice• Suggestions for how the PPI could be resolved and how you could support this• A request for the manager to follow up with you by a certain time.

Then follow up any conversations with your manager with written communication, such as a letter. A template that could be helpful when developing a letter can be found in the Resolving Professional Practices Tool Kit on page 11.

If there is a risk to client safety as a result of any PPI, steps to ensure client safety need to be taken immediately and your manager must be notified.

Your standards of practice and code of ethics are two important documents to help you frame these conversations. By using the standards and code of ethics, you can take the focus of the conversation away from you personally and place it on your professional standards that you are required to meet. This can be achieved by explaining to your manager how the PPI impacts on your ability to meet these professional standard(s).

Adopting a Solutions Focused ApproachA solution-focused approach is helpful to keep everyone focused on the goal and to maintain momentum towards a resolution.

To adopt a solutions-focused approach, you would:

• Look towards the future by clearly stating what your goal is and then decide what you need to do to move towards this goal.

• Rid yourself of any assumptions you may have and let go of blame .• Gain different perspectives by talking to and involving others.• Keep things simple and stay focused on the goal.• Avoid dwelling in the past as this can prevent you from moving forward towards resolution and slowing

down progress.

PLEA

SE

NO

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EXERCISE 6: SCENARIO

Here is a scenario to apply the information we just covered.

Elaine usually finishes her client assignment well before everyone else, despite the fact that the unit is currently adopting a new assessment scoring model for orthopedic clients. The scoring system is being adopted across Canada and the data collected as part of a national research project.

Elaine has repeatedly informed her nursing colleagues that the old assessment system works fine so she has no intention of learning a new system. Besides, she feels it takes too much time for the same results. Terry, the charge nurse, can see how on the surface this may appear to be true but knows that the study to date has been successful in identifying risk of client complications earlier which has been improving client outcomes

Elaine sees no value in the new assessment system and is refusing to attend the in-services or apply the scoring system. Terry believes Elaine provides safe care overall and knows she is planning on retiring in six months.

a. Do you feel this is a PPI? Why or why not?

b. What would you like to learn more about by exploring this issue (questions in step two)?

c. What do you feel are underlying cause(s), (contributing factors) of the issue?

d. What resources could be accessed to address the issue?

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e. What possible actions could Terry take to demonstrate a solution focused approach?

This situation is a PPI because Elaine’s actions are negatively affecting client care and she is not practicing according to her standards of practice. For example, she is not meeting the indicator 2.10 of the Standards of Practice; each Registered Nurse promotes practice environments that encourage learning and evidence informed practice.

Some important things to learn more about this situation could include the type of training the staff have had to date, what expectations have been communicated to the staff, finding out if anyone has spoken to Elaine about the situation and determining if any other steps have been taken to address this situation so far.

In terms of underlying causes, it would appear that Elaine has not bought into the study. This could be because she does not see the value in it, does not adjust easily to change, or perhaps because she is wanting to simplify her practice as she nears retirement.

Possible resources that could be used as you work to resolve the issue with Elaine and the team could include the Standards of Practice, Code of Ethics, agency policies and procedures, the manager, other coworkers, information on the study results, evidence showing the impact on client care, research articles, a physician or a staff member that Elaine is close to or holds in high regard.

Actions to demonstrate a solution focused approach could include:

• Having a discussion with Elaine, incorporating available evidence

• Explaining to Elaine how her actions are not meeting her standards of practice

• Meeting with staff to review the study and expectations, to identify and address any issues as a team, and share how it’s improving care

• Having a discussion and involve the unit manager.

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STEP FIVE

Documentation ensures you have an accurate account of events and are able to demonstrate that you have met your professional obligations and standards of practice in your attempts to address the PPI.

For example, if for some reason a client is negatively affected by the PPI, you will be able to show the steps you have taken by sharing the documentation with the appropriate person if your actions are called into question.

Keep personal records of everything you do to resolve the PPI. Any meetings you have with managers and other leaders of your organization should be noted in your personal records and then followed up in a written form as soon as possible, as indicated in step four on page ten. The CRNNS Duty to Report Practice Guidelines (crnns.ca/wp-content/uploads/2015/02/PracticeGuidelineDutyToReport.pdf) is a helpful resource as it provides further information about your legal and ethical responsibilities related to reporting and documenting challenging situations in practice.

The client chart is not where you document discussions related to a PPI. Depending on the situation though, you may be required to document the PPI in an adverse event monitoring system and, if there is a direct impact on the client, it may be appropriate to record that information in their chart. Check your organization’s policies regarding documentation and/or refer to the CRNNS Documentation Guidelines for Registered Nurses (crnns.ca/wp-content/uploads/2015/02/DocumentationGuidelines.pdf) for more information regarding principles of documentation.

STEP 6

The final step is to evaluate if the PPI has been resolved and how your actions have impacted on the issue. When evaluating, consider what you would do differently if faced with a PPI again. If the PPI has been addressed by involving others, perhaps with the support of your team or by working with your manager, it is important to include them in the evaluation process as well.

If you and/or the team determine the PPI has not been resolved, part of your evaluation then becomes determining what changes are needed to your approach

and continuing to take steps until it is resolved.

Step back and consider possible reasons why by asking yourself and your team these questions:

• What could you and/or the team have done differently?

• Was the issue clearly identified?

• Did you fully explore the issue?

• Were the resources correctly identified?

• Did you share how/when the client was affected?

• Were the right people involved?

• Is there evidence of steps taken to address the PPI?

DOCUMENT

5.

EVALUATE

6.

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Based on this evaluation, choose your next steps. If the PPI continues to exist and to affect client care, especially if client safety is at risk, you need to continue to take action until the issue is addressed.

You likely would have already met with your manager well before this point but if not, this would be your next step. At any meeting, be sure to clearly identify the issue and provide your thoughts around how it could be resolved in the best interest of client care. As previously mentioned, follow up any meetings with written communication outlining the discussions. Be sure to stress the importance of the issue and indicate a reasonable date when you hope to hear back from manager.

If you have previously met with manager or the issue persists after a reasonable amount of time following your meeting, the next step would be to meet with your manager again.

In extreme cases, when the issue is a risk to client safety, inform your manager that your standards of practice require you to either notify your regulatory body (CRNNS) and/or notify the manager’s direct supervisor. For more information, please refer to the CRNNS Duty to Report Practice Guidelines. Sometimes there are system factors at play that can impact on professional practice issues. By working through the PPI framework, you will have met your standards of practice, even if the issue has not been resolved to your satisfaction.

Continue to notify the appropriate people and carry the PPI forward until the issue has been resolved. If your manager communicates they are taking action to resolve the issue, it is okay to ask them to touch base with you when they have done this. Just be aware that, because of confidentiality issues, your manager may not be able to discuss specifically the actions they have taken and what the outcomes were. They may only be able to let you know that they have addressed the issue, which is acceptable.

EXERCISE 7: REVIEW

You have nearly completed the workbook. Here are some review questions.

1. You have met with your manager and explained the PPI to them and followed up with a letter. You have now met all of your professional obligations.

True or False

2. Your manager does not get back to you to indicate they have addressed the PPI and you notice that the PPI continues to occur. What steps would you take now?

3. Nurses can use their professional standards of practice and code of ethics to help frame any discussions about a PPI to help take the focus of the conversation away the nurse and place it on the standards that nurses are professionally required to meet. True or False

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4. What are three things that should be included in written communication sent to a manager following a meeting to discuss a PPI?

The answer to question one is false and the response to question two can be found on page fourteen, continue to keep addressing the issue until it is resolved (as best that you can). Question three is true and four, the answers can be found on page ten.

In summary, professional practice issues can occur in all practice settings. RNs and NPs are required both legally and professionally to take action to resolve PPIs. Our responses, as we work to resolve or minimize these issues, can affect the impact they can have on clients and our practice.

If a nurse is not able to resolve an issue them self and/or client safety is at risk, the manager needs to be involved and in extreme cases, a determination made if CRNNS needs to be notified. Use your standards of practice and code of ethics as guides as you work through this process.

Please remember that you can consult a practice consultant at CRNNS for help if needed. If client safety is compromised, as nurses we need to meet our standards of practice by focusing on ensuring that client’s safety is the priority.

Congratulations! You have reached the end of the workbook. Feel free to use the workbook when completing the post-quiz. Just another reminder that you must successfully complete the post quiz to meet one of the Continuing Competence Program requirements.

And as always, please contact us at practice@crnns.ca if you have any questions or require clarification on any aspect of the workbook or would like to discuss an issue in your nursing practice.

When you feel ready, please complete the mandatory post quiz found on the member’s portal (members.crnns.ca). Once you have successfully completed this quiz, CRNNS will automatically be notified and you will then have an opportunity to provide your feedback on the workbook and the Continuing Competence mandatory education.