Nursing 1050 Review For Final

Critical Thinking

 Critical thinking is used throughout education and work

 Questioning is one method that fosters critical thinking
 Questioning is based in philosophy
 Sometimes questions are more important than answers
 The power to question is the basis of all human progress
 Start to think of the questions yourself; do not just take the answers for truth
 It is important to question both what you are told and what you observe
 Questions stimulate our thinking process and bring you to a deeper understanding
 Questions lead us to a holistic journey with multiple paths
 In nursing it is important to think broadly, beyond your skills
 Advances in medicine would not have happened without critical thinking and
challenging the status quo

Thinking

 Thinking: conscious engagement

o Idea, thought, or perceived problem
o Includes reasoning
 Inductive reasoning: using specific events or scenarios to form broader generalizations “inside
the lens”- cause and effect reasoning (specific events have happened, so they will probably
happen again)
 Deductive reasoning: making generalizations backed up by specific conclusions or information
“outside the lens” (taking generalizations of everything and making it into a specific situation)
 Reasoning helps make decisions

Common though processes

 Reasoning processes are helpful to solve  Planning- conscience process of thinking

problems, make decisions, or gain deeper ahead and know how you achieve goals
understanding about a particular topic or  Predicting-forecasting based on previous
interest knowledge and thoughts
 Decision making  Problem solving
 Distinguishing  Rationalization- engaging in a situation to
 Evaluating find optimal conclusion
 Hypothesizing  Reflection- looking inward
 Making inferences  Synthesis- combining small bits of
 Memorization information to create a larger conclusion
 Organizing-classifying thoughts into  Translating- changing items of thought into
categories eg) level of importance other formats
 Understanding- reaching a state of
comprehension

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 Thinking vs. Critical thinking

 The distinction between thinking and critical thinking is based on the reason, content and
process of thinking
 Critical thinking is a purposeful process that is:
o Reflective (thinking about your thinking)
o Consecutive (follows logical sequence)
o Goes beyond recognition of an initial thought (going and thinking further and broader to
come to a conclusion)
 Critical thinking is important for our everyday thinking as well as in our lives
 Without critical thinking, a deeper understanding of knowledge would not occur, leaving nursing
care essentially ineffective
 From knowing to being: Thinking about and deciphering what is important knowledge in the
moment, translating the knowledge to understanding and prompts you to action.

Defining Critical Thinking

 Prominent Definitions:

o Delphi method o Scheffer and Rubenfled (specific to

o American Philosophical Association nursing)
o Alfaro-LeFevre (specific to nursing)

Using the Delphi Method

 This method comes from outside nursing  They respond to a variety of questions and
 It is one of the most popular definitions of their opinions are recorded
critical thinking  The questions lead to a deeper inquiry
 Experts collaborate to create a definition  Consensus is achieved and a definition is
through consensus created
 Expensive and can take years to complete

Facione APA

 Purposeful, self-regulated judgement  The idea critical thinker is inquisitive,

 Results in interpretation, analysis, systematic, judicious, truth-seeking,
evaluation, inference confident in reasoning, open-minded and
 Explanation of the evidential, conceptual, analytical
methodological, criteriological or contextual
considerations

Scheffer and Rubenfeld

 Specific to nursing
 Developed one definition in collaboration with nursing scholars
 Skills and dispositions important for critical thinking
 Importance of critical thinking in quality nursing practice

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  Critical thinking is an essential component of professional accountability and quality nursing
care
 Critical thinkers exhibit confidence, contextual perspective, creativity, perseverance, flexibility,
inquisitiveness, intellectual integrity, intuition, open-mindedness, and reflection.
 Critical thinkers practice the cognitive skills of analyzing, applying standards, discriminating,
information seeking, logical reasoning, predicting and transforming knowledge.

Alfaro-Lefevere

 Specific to nursing
 Critical thinking is the process resulting in clinical judgment in nursing practice
 Purposeful, informed and outcome-focused thinking
 Based on the principles of the nursing process, problem solving and the scientific method
 Focuses on safety and quality, constantly re-evaluating, self-correcting and striving to improve
 Guided by standards, ethics codes, policies and laws
 Compelled by patient, family and community needs
 Uses logic, intuition, and creativity and is grounded in specific knowledge skills and experience
 Focuses on nurses needs to give competent and professional care

Similarities of the Facione/Scheffer and Rubenfeld/ Alfaro-Lefever definitions

 All include the following cognitive processes: decision making, problem identification and
problem solving

Differences of the Facione/Scheffer and Rubenfeld/ Alfaro-Lefever definitions

 Alfaro-Lefevre and Scheffer and Rubenfeld include intuition as an important part in nursing
definitions of critical thinking, where it is not part of Facione
 Only Alfaro-LaFevre included the clients, families and communities as part of the definition
 Facione and Scheffer and Rubenfeld identified skills and dispositions, but Alfaro-LeFevre does
not include any attributes

Critical Thinking Involves

 Purposeful process
o Reflective: thinking about your thinking, why you are thinking that way and evaluation
its purpose and process
o Beyond recognition of an initial thought
 Disposition

o Open-minded: showing tolerance for different viewpoints

o Creativity: thinking outside the box, leads to new insights
o Analytical and Intuitive: expressing deep understanding by analysing
o Self-aware: aware of your own inner qualities, how your emotions affect your thinking,
identifying your own personality
o Curiosity and inquisitive: asking questions
o Interactive: sincere engagement

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 More than just cognitive skills

o Ability to ask questions o Be honest in facing personal biases

o Be well-informed o Be willing to reconsider and think
clearly about issues

Why Nurses need Critical Thinking

 Social and personal growth- by using critical thinking in our everyday relationships, we are
better able to reflect and adjust our thinking, perceiving and actions as the relationship grows
 Economical and workplace success- instrumental for nurses to function in a fast-paced health
care setting and when working with acutely ill clients or those with complex health needs. Using
analysis, interpretation, evaluation and reflection, nurses can enhance their understanding of
the complex factors that affect clients and their families.
 Political, Moral and Ethical-advocating for the greater good, thinking about being connected to
the world around us. Actions follow thinking.

Developing Critical Thinking

 Internal processes
o Reflecting on values, assumptions and thinking
o It is important to explore assumptions and ask yourself why you are thinking the way
you are
o Thinking can be emotion-based and that can lead to what you do
 External processes
o Engaging in critical questioning
o Writing to develop and communicate thoughts

Importance of critical thinking

 Asking yourself critical questions before providing nursing care is an important safety aspect of
nursing practice
 Without critical thinking, you will not consider important information that will better direct you
to nursing care
 This makes your care less effective and potentially unsafe for the client

Levels of Critical Thinking

 Basic critical thinking

o the learner trusts that experts o thinking is concrete

have the right answers for o not thinking on your own;
every problem taking somebody else’s word

 Complex Critical thinking

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 o Separate your thinking from o A willingness to consider other
“authorities” and begin to analyze options or explanations
and examine your own choices o Thinking is more creative and
independently innovative
o Still listening to other people as well

 Commitment
o Anticipate the need to make choices without assistance and assume the
responsibility/accountability for those choices
o Give attention to the results of the decision and determine whether it was appropriate

Using Research

 Evidence-informed practice: all of what we do is founded in systematic research; figure out what
is the best source
 Evaluating source of evidence: where is my info coming from? Is it valid?
 Reading critically: the way you read is just as important as what you read
 Applying thinking to practice: without knowledge, critical thinking is limited

Academic Writing in Nursing program: APA guidelines

APA Style

 Use headings: organizes the paper (helpful to you and reader)

 Use transitional words: helps with continuity of ideas (ex. Therefore, consequently,
furthermore)
 smoothness of expression: clear and logical conversation (no surprises)
 use verb tenses consistently within sections
 economy of expression: less is more, only say what needs to be said
 precision and clarity: avoid colloquialisms (phrases used in conversation) and jargon
 avoid unclear referents (pronoun use)
 Abbreviations: first time, write out completely, followed by abbreviation in parenthesis,
then you can use abbreviation in rest of paper

APA mechanics

 Review when writing as needed:

o Spacing after punctuation o Dashes

o Periods and commas o Hyphenation
o Semicolons and colons o Numbers

APA Format

 12 point font, Times New Roman  2.54 cm (1 inch) margins

 Double spaced, with no extra space added  Page numbers, Times New Roman, top
between paragraphs right)

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 APA Crediting Sources: Citations

 Citing is crediting sources  Cite when not using  You must have read the
to prevent plagiarism common knowledge cited work

Paraphrase vs. Direct Quote

 Direct quote: verbatim from source; need to include the quotes as well as the page number in
citation
 Paraphrase: rephrasing work from source; need to cite
 Paraphrase often and quote sparingly: overuse of quotations leads to poor flow

APA In Text Citations

 When using a direct quote, in parenthesis put author, year of publication and page number (eg.
Doane & Varcoe, 2020, p.98)
 When paraphrasing, put author and year in parenthesis, if citing after statement (eg. Doane &
Varcoe, 2020) or author followed by date in parenthesis, if using it at the beginning of the
statement (eg. Doane & Varcoe (2020) describe………..)

APA crediting sources

 One author: cite name every time (Smith, 2021)

 Two authors: cite both names every time (Smith & King, 2021)
 Three or more authors: cite first author’s name followed by et al. (Smith et al., 2021)

APA Reference List

 “References” in bold, centred on  Alphabetical order

last page  Hanging indent
 Double spaced

APA References- Process

 Determine what you are referencing (book, chapter, edited book, periodical, website)
 Look it up in the APA manual
 Can use google scholar for articles, but compare it to the manual often as can be incorrect
 Option to use Zotero/bibliographic software, but compare it to manual often as can be incorrect

Avoiding academic dishonesty

 Give credit to the author, do not copy and paste then not cite
 Never purchase papers

Resources to Help

 APA manual  Writing centre at LU

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 Grammarly  Bibliography software (Zotero)
 Owl Purdue  Your instructors
 Google Scholor “cite” button

Reflection and Reflexivity

Reflection

 Reflection: a process that is key to becoming an artful and skilled nurse (manual skills, ability to
connect with clients, etc)
 The act of wondering about a phenomenon and seeking its deeper understanding (thinking
about what is really going on, learn through experiences, making meaningful observations,
responding to clients questions)
 Reflection on action:
o Thinking back and considering how we have done
o Asking yourself “How did the client respond to my actions? What might have influenced
that response? What could I have done differently?”
o Journalling
o Shapes your future practice
 Reflection in action:
o Occurs at the moment, when engaged in a particular situation with a patient
o Is the client responding the way you expect? How can you adjust your approach to
obtain a better result?
o Shifting your focus to how the client is responding
 3 simple questions that cam be used to help nurses reflect on their practice:
1. What? (What happened?; think about the key details and try to consider multiple
perspectives)
2. So what? (Reflect on what occurred by thinking about what motivated the actions and
how the situation could have been different)
3. Now what? (formulate an action plan by determining how you will approach a similar
situation in the future or by identifying the knowledge and skills you need to develop.

Reflection vs. Reflexivity

 Reflection: asking questions about what we have done or are doing

o Considering the key elements of a situation, asking questions about what factors led to
particular outcomes
o Determining what different types of actions might be taken in the future
 Reflexivity: moves us deeper into critically considering and questioning the assumptions and
values that motivate and undergird our nursing practice
o Considering taken-for-granted assumptions
o Asking questions about what might underlie our actions or the practices in a system
o Critically determining what person or system changes might need to be made

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 Reflexivity

 Pushes us to be aware of our own interests and motivations

 Encourages us to consider the power, privilege and biases that may affect our client
relationships
 ‘othering’: when people think they are different than the mainstream and themselves, they
think they are better than other people
 Being reflexive can prevent us from ‘othering’

Benner’s Competency Domains in Nursing Practice

1. The helping role
2. The teaching or coaching function
3. The diagnostic monitoring function
4. Effective management of rapidly changing situations
5. Administering and monitoring therapeutic interventions and therapeutics
6. Monitoring and ensuring the quality of health care practices
7. Organizational and work-role competencies
 It is important to reflect on our knowledge, skills, abilities and how we gain expertise over time
 Benner states that nurses accrue practical knowledge over time

Benner’s Five Stages of Expertise

1. The novice:
o Lacks experience
o Uses rules to guide practice
o Does not necessarily pick up contextual cues
o Uses attributes of a situation or measurable parameters to make decisions
2. The advanced beginner:
o Has enough real-life experience to understand the meaning of contextual cues
o Can develop guidelines for action
o Starts to hone ability to identify relevant aspects of a situation
3. The competent practitioner:
o Sees actions in relation to long-term goals or plans
o Able to outline most important aspects of the situation
o Uses conscious, deliberate planning
o Is efficient and organized
o Knows what to expect in a typical client’s situation
o Can modify plans when expectations are not met
4. The proficient practitioner
o Perceives situations as a whole
o Understands long-term implications
o Knows how to read nuances
o Decision-making is less laboured
o Can quickly decide what is required
5. The expert

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 o Does not always rely on rules to connect the understanding to a situation
o Has an intuitive grasp
o Able to quickly zero in on what is required

Bodies and Physical Care

 Minifisms: minimizes embarrassment/masks nurses shock (ex. Minimizes an accident that the
patient had to save them embarrassment)
 Asking visitors to leave to perform intimate body care
 Discourse privatization: speak quietly and away from others when having private conversations
with patient about bodily functions
 Managing nauseating situations and body products: nurses can focus on details of the task, take
time by offering a plausible excuse to leave room to get yourself together, or focus on the
experience of the client instead of own concerns

Art of Nursing: The 5 Senses

 Nurses are not merely technicians, they cannot simply select from a list of interventions and
apply them to a client- we are thinking holistic
 There is an art involved in providing excellent nursing care
 Johnson set out to consider how the nursing art has been conceptualized by nursing scholars
since the days of Florence Nightingale and now to the modern era
 The study brought to light 5 separate “senses” of nursing art:
1. the ability to grasp meaning in client encounters

o determines the significance o takes in the whole client

of what is seen, heard, o grasps meaning
touched and smelled o senses patterns
o determines the significance o uses intuitive capacity
of emotions, objects, o uses a holistic approach
gestures, and sounds

2. the ability to establish a meaningful connection with the client

o creates a quality connection o makes a genuine

with the client connection
o expresses authentic o lets go of other concerns
concern, compassion and and tasks while caring for
care the client
o is emotionally sensitive to o pays attention to what a
other human beings client is saying
o is affirming clients as
human beings

3. The ability to skillfully perform nursing activities

o Develops skills dexterity or

proficiency

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o Integrates principles, o Seamlessly integrates
procedures and techniques principles into action
into practice

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 o Develops client-centred
goals

4. The ability to rationally determine an appropriate course of nursing action

o Has a keen intellect o Uses interventions and ends

o Is action oriented and reasoning
focused on producing o Has an action orientation
particular outcomes o Has a vision for the client
o Applies logical reasoning

5. The ability to morally conduct one’s practice

o Avoids harm to clients o Is committed to providing

o Strives to benefit the client competent care for clients
o Makes moral choices in the o Sustains excellent practice
performance of care o Is caring and concerned for
others

Canadian Health Care System and Interprofessional Practice

Canadian Healthcare system

 Organization and responsibilities of Canada’s health care system is outlined in the constitution
 The Canadian healthcare system is composed of the health services provided by health
professionals to eligible residents, ensuring they have reasonable access to medically necessary
insured services on a prepaid basis without direct charges
Approaches to Health

1. Medical 3. Socio-
2. Behavioral economical

Medical approach to Health

 Early/mid 20th century o No focus on prevention

 Focus on curing o Heavy reliance on physicians/in
o Health problems pathologized patient (hospital) care, nurses
(focus on curing) o Procedures, rather than something
o Medical intervention emphasized to the patient can do themselves
restore health o Unaffordable for a lot of people

o People wouldn’t get the care they need because of money

 Until 1966, payment was out of pocket
o Tommy Douglas from Sask. went into government in 1947 and was first to introduce
socialized medicine (government funded healthcare)

Behavioural approach to health

 1970’s

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 Increased government spending on healthcare but not significant improvement in health
 People were not getting healthier
 Lalonde Report (1974)
o Health is broader than just sickness and there is more to health than the quality of
health care services
o proposed these determinants of health: environmental, biology, health services and
lifestyle
o neglected socioeconomic, sociocultural, environmental and geographical barriers
 promotes individual responsibility for health
 people can be taught how to be healthy
 poor health can be contributed to lack of knowledge
 individuals can’t be separated from their context and that can affect their care for their own
health
 Epp Report (1986) Canadian minister of heath and wellness

o expanded on Lalonde o Prevent disease

o Disadvantaged groups o Enhance coping
o Detect and manage disease

 Ottawa Charter (1986)

o based on Lalonde report

o proposed health promotion as the “process of enabling people to increase control over,
and to improve, their health”
o recognizes prerequisites to health: peace, shelter, education, food, income, social justice
and equity

 Health promotion actions means:

o Build healthy people policy- creating frameworks for people to live within
o Create supportive environments-addressing if there is something in community that
needs to change to promote health
o Strengthen community action
o Develop personal skills
o Re-orient health care services

Socio-environmental approach to Health Care

 Understanding of social determinants of health led the way for a socioenvironmental approach
to health
 Builds on behavioural approach but also emphasizes social context and environment
 Social context: what would be contributing to someone’s health where they are living
 Acknowledges that health is self-defined (in that someone can be healthy even with a disease)
 What are a person’s goals
 Helping them to cope with or change socioenvironment so that their health can be improved

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 Social determinants of health

 the non-medical factors that influence health outcomes.

 Conditions in which people are born, grow, work, live and age
 Wider set of forces and systems shaping conditions of daily life
 Economic policies and systems, developmental agendas, social norms, social policies and
political systems
 Social determinants of health which can influence health equity in positive and negative ways

o Income and social protection o Early childhood development

o Education o Social inclusion and non-
o Unemployment and job insecurity discrimination
o Working life conditions o Structural conflict
o Food insecurity o Access to affordable health services
o Housing, basic amenities and the of decent quality
environment

 Research shows that social determinants of health can be more important than healthcare or
lifestyle choices in influencing health
 Numerous studies suggest that social determinants of health account for between 30-55% of
health outcomes
 Estimates show that the contribution of sectors outside health to population health outcomes
exceeds the contribution from the health sector
 Addressing social determinants of health appropriately is fundamental for improving health and
reducing longstanding inequities in health, which requires actions by all sectors and civil society

Raphael’s Traditional 10 tips for better health

1. Don’t smoke. If you can, stop. If you 6. Cover up in the sun, and protect
can’t, cut down children from sunburn
2. Follow a balanced diet with plenty of 7. Practice safer sex
fruit and vegetables 8. Take up cancer-screening opportunities
3. Keep physically active 9. Be safe on the roads: follow the
4. Manage stress by, for example, talking Highway Code
things through and making time to relax 10. Learn the First Aid ABC’s
5. If you drink alcohol, do so in
moderation

Raphael’s Social Determinants 10 tips for better health

1. Don’t be poor. If you can, stop. If you 6. Be able to afford to go on a foreign

can’t, try not to be poor for long holiday and sunbathe
2. Don’t have poor parents 7. Practice not losing your job and don’t
3. Own a car become unemployed
4. Don’t work in a stressful, low-paid 8. Take up all benefits you are entitled to,
manual job if you are unemployed, retired or sick or
5. Don’t live in damp, low-quality housing disabled

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9. Don’t live next to a busy major road or before you become homeless and
near a polluting factory destitute
10. Learn how to fill in the complex housing
benefit/asylum application forms

Canada Health Act

 The act sets out the primary objective of Canadian health care policy, which is “to protect,
promote and restore the physical and mental well-being of residents of Canada and to facilitate
reasonable access to health services without financial or other barriers”
 Federal legislation: governs how provinces receive federal funding
 Guaranteed access to essential medical services: regardless of employment, finances, health
Five Pillars of Canada Health Act
 Public administration
o Each provincial or territorial health insurance plan must be administered and operated
on a not-for-profit basis by public authority
o Public authority is accountable to its respective provincial or territorial government for
decisions regarding benefits and levels of service, and its records are publicly audited
 Comprehensiveness
o Health care insurance plan of a province of territory must cover all insured services
provided by hospitals, physicians or dentists (dental services that require surgery in a
hospital setting) and where the law of the province permits select services provided by
other health care practitioners for eligible people
o Must be available to all provincial or territorial residents with equal opportunity
 Universality
o All insured residents of a province or territory are entitled to the insured health services
provided by their respective provincial or territorial health insurance plan on uniform
terms and conditions
o All residents must register with their respective government to receive benefits
o For new residents of Canada, there will be a waiting period that must not exceed 3
months
 Portability
o Residents moving from one province or territory to another continue to be covered for
insured health services by their home jurisdiction during any waiting period (not more
than 3 months) before coverage is transferred to their new jurisdiction.
o During any temporary absence from home province, or territory, or from Canada,
insured health services coverage continues for a prescribed period of time set by each
province and territory.
o This is intended to provide seamless coverage in the event of an emergency or urgent
need during temporary absence.
o This does not entitle a person to seek health services outside their home province
 Accessibility
o Protects all insured people of Canada’s provinces and territories from extra charges for
health care or from discrimination

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 o Guaranteed reasonable access to insured hospital, medical, and surgical-dental care on
uniform terms and conditions without discrimination based on the basis of age, health
status, or financial circumstances.
o Reasonable access mean access to services when and where they are available, as they
are available (eg. An insured person must be granted access to a service in another
jurisdiction if the health care service is required but is not available in their home
territory or province)

Organization of Canada’s Health Care System

 Federal Administration
o Health Canada
 outlines the principles of health care for Canadians.
 Provinces and territories must follow these principles to manage and provide health
care for their residents under the authority of provincial and territorial ministries of
health
o Minister of Health
 Elected Member of Parliament to the position by the Prime Minister
 Responsible for promoting, preserving, and improving the health of the people of
Canada
 Oversees the health-related laws and regulations and works collaboratively with the
provinces and territories on health system issues
 Responsible for preparing a report on how each province/territory are meeting the
regulations.
 Federal branches and agencies (don’t need to memories branches)
 Provinces and territories
o 13 separate health care insurance programs
o Each province and territory is responsible for managing and providing primary, secondary
and tertiary health care for its citizens
o Each province or territory determines the services covered; therefore, this varies across the
country
 Regionalization
o Every province and territory has undertaken regionalization of health systems by
forming RHAs (regional health authorities)
o This decentralizes decision-making and streamlines services to defined geographic
regions to address health care needs in that region
o RHAs oversee hospitals, long-term care, residential and acute care services, and in some
regions, public and mental health, addiction and health promotion programs

Points of Care- where can you access health care?

 Primary health care (family doctors,  Tertiary health care (acute care
NPs, public health unit, nurses) teaching hospital)
 Secondary health care (referrals to  Quaternary health care (typically
specialists, community hospital, long specialized acute care hospital, such as
term care) paediatric hospital)

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 Health Care Reform

 Primary health care reform

o Shift from individual health provider to team based care (interprofessional)
o Shift to health promotion and prevention
o Telemedicine
 Secondary health care reform
o Restructuring of hospitals
o Electronic health records

Interprofessional Practice

 Interprofessional collaboration is essential to high quality integrated care

 IPC occurs when a variety of health care providers work together with patients, families and
communities to provide integrated and comprehensive services of highest quality across settings
 Improves health outcomes, decreases costs (less duplication of services, length of stay), reduced
errors, less staff turnover
 Members of interprofessional health care team:

o Community health workers o Physicians/residents/physician

o Dieticians assistants/specialists
o Discharge planners o Physiotherapists
o Occupational therapists o Social workers
o Nurses/nurse practitioners o Speech language pathologists
o Personal support workers o Respiratory therapists
o Pharmacists o Spiritual and religious care
o Unit care aids

Health Care and the Law in Canada

 Branches of law
o Public law

 A.k.a criminal law  Crime and actions

 Relationship between considered harmful to
government and society
citizens

o Private law
 Relationship between individuals
 Governed by 2 legal traditions:

 Common laws in  Civil law in Quebec

most of Canada

 Includes tort law (negligence)

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  Judges base decisions on previous cases that are similar
 This law is not written down
 Ex. Invasion of privacy
 Civil law are laws that are written down in codes
o Statute Law
 Tells you what to do to report things such as elder or child abuse
o Aboriginal Law or Indigenous Law
 Laws that adhere to indigenous people where they can govern themselves and
territories

Law and Health

 Provinces have laws and regulations on running health care facilities

 Federal legislation: The Canada Health Act- provides foundation for Canadian health care system
(eg. Health care services for Indigenous people, regulating pharmaceuticals)
 There are laws related to client rights (eg. Right to receive safe care, right to refuse consent,
right to participate in health care decisions, right to ask questions and express concerns, right to
be assured personal information is confidential, right to access or obtain own health records,
right to transfer health records from one health facility to another)
 Many other laws affect human health that are not specific to health and healthcare, such as
environmental laws, social policy etc.

Tort Law

 Cornerstone of the Canadian legal system

 Vast area of private law
 Involves a victim and a wrongdoer
 May be:
o Intentional (though no physical injury is required)
o Unintentional (negligence)
 Does not cover criminal law
 Can be physical or mental harm or negligence

Tort Law: Intentional

 Assault
o Attempt or a threat to touch another person
o Requires intent
o Can be negligence
o Assaulting individual does not carry out what they were going to do (threat)
 Battery
o Touching someone without consent
o No physical harm needed (harm to dignity)
o Nurse doing procedure against their will
o If person is injured and procedure was not approved by patient, they can be charged
with negligence

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 Defamation
o Communication resulting in harm to reputation
o Be careful on social media
 False Imprisonment
o Prevented from leaving an area
o Threat can be false imprisonment
o Restraints not considered false imprisonment in some contexts: need to determine the
capacity for consent, if someone is a danger to themselves or others, need to get orders
from doctor
 Invasion of Privacy
o Release of information to third party without consent
o Exceptions: births, deaths, infections, communicable diseases, child or elder abuse,
violence such as stab or gun wounds

Tort Law: Unintentional (Negligence)

 When an individual or entity unintentionally or inadvertently behaves in a way that causes

another person harm, it is categorized as an unintentional tort (negligence)
 4 elements must be proven by the plaintiff before the negligence claim can be successful:
1. The defendant (nurse) must owe the plaintiff (patient) a duty of care
2. The defendant must breach the standard of care established by the law
3. The plaintiff must suffer and injury or loss
4. The defendant’s conduct must cause the plaintiff’s injury
 Inexperience is not an excuse for negligence
 Legal duty to follow orders and intervene in a physician’s orders if you think they are not correct

Breaches to Standard of Care

 Failing to communicate with other  Failing to follow hospital policy

health professionals in a timely fashion  Failing to intervene when there is clear
 Failing to properly monitor and assess and obvious neglect or incompetence
clients on the part of another health
 Failing to maintain proper records professional

Defenses

 Error of judgement  Vicarious liability: when the negligence

 Approved practice of the nurse is held by the court to be
the responsibility of his or her employer

Avoiding Negligence

 Provide competent care  Insist on appropriate staffing

 Follow standards of practice, protocols,  Communicate with others
procedures, etc  Document fully
 Insist on orientation, continuing
education

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 Understand expectations regarding consent:
o Implied vs. expressed
o Elements (voluntary, capability, individual performing treatment, informed)
o Substitute decision maker (SDM)

CNO Practice Standard: Confidentiality and Privacy- Personal Health Information

 Nurses have ethical and legal responsibilities to maintain the confidentiality and privacy of
health information obtained while providing care
 One way that nurses maintain boundaries and build nurse-client relationships base on trust is by
respecting clients’ rights around confidentiality and privacy
 Ontario’s privacy legislation supports and extends the College of Nurses of Ontario’s standards
on nurses’ accountabilities pertaining to clients’ personal health information
 The Personal Health Information Protection Act, 2004 (PHIPA)
o Governs health care information privacy in Ontario
o Information privacy is defined as the client’s right to control how personal health
information is collected, used and disclosed
o PHIPA sets consistent rules for the management of personal health information and
outlines the client’s rights regarding their personal health information
o This legislation balances a client’s right to privacy with the need of individuals and
organizations providing health care to access and share health information
o PHIPA permits the sharing of personal health information among health care team
members to facilitate efficient and effective care

Information and Privacy Commissioner of Ontario

 Snooping on a patient could cost you:

o Your o College o $50,000 in

reputation disciplinary fines
o Your career action o A civil
lawsuit

CNO (2019) Practice Standard: Code of Conduct

 This code of conduct is a standard of practice describing the accountabilities all Ontario nurses
have to the public.
 It articulates what the people of Ontario can expect and sets the bar for those in the nursing
profession
 The code consists of 6 principles:
1. Nurses respect the dignity of patients and treat them as individuals
2. Nurses work together to promote patient well-being
3. Nurses maintain patients’ trust by providing safe and competent care
4. Nurses work respectfully with colleagues to best meet patients’ needs
5. Nurses act with integrity to maintain patients’ trust
6. Nurses maintain public confidence in the nursing profession

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 CNO (2019) Reference Document: Professional Conduct, Misconduct Document

 Acts that constitute a breach or abuse of the nurse-client relationship are considered
professional misconduct, as it is conduct that demonstrates a lack of integrity
 A nurses conduct that is harmful in any way, or that undermines or detracts from the
professional caring relationship with and for the client, is not consistent with expected
professional standards
 Acts of professional misconduct may result in an investigation by the College, followed by
disciplinary proceedings
 As set out in the legislation, the College investigates all complaints about nurses
 The College also receives mandatory reports of termination of nurses from employers
 Professional misconduct includes:

o Failure to maintain standards of o Inadequate documentation and

practice record keeping
o Working while impaired o Misrepresentation
o Abusive conduct o Failure to meet
o Theft legal/professional obligations
o Failure to obtain informed o Conflict of interest
consent and breach of o Inappropriate business
confidentiality practices
o Disgraceful, dishonourable, and
unprofessional conduct

o Other grounds for professional misconduct:

 Guilty of offense
 Sexual abuse
 Professional misconduct in another jurisdiction
 Directing a member, student or other health care team member to perform nursing function for
which he/she is not adequately trained or that he/she is not competent to perform

Implications for Nursing Students

 Accountable for actions

o To client/practice site
o To educational institution
 Practice in a reasonable and safe manner
 Never perform care you are unprepared to perform
 Recognizes his/her knowledge, skills and judgement, limits of responsibilities, and supervision
requirements
 If a student is harmed, the following will be involved in the reporting process:

o Student o Hospital/institution
o Instructor o University

Person Centred Care, Diversity and Health, Immigrant and Refugee Canadians

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 Background info: Census Data
 21.9% of the population reported they were a landed immigrant or permanent resident in
Canada
 This accounts for about 1/5 of the population
 Migration accounts for about 2/3 of Canada’s growth
 Recent immigrants accounted for 3.5% of population in 2016
 Highly populated provinces welcomed the most immigrants between 2011 and 2016
 Federal government’s objective is to attract 1.3 million new permanent residents between 2018
and 2021
 People come to Canada for a better life, better politics, natural disasters, safer, better economic
structure

Context of Migration to Canada

 Migration for economic, employment and social opportunities

 Addresses shortages in labour sectors (historically)
 Humanitarian responses (more recently)
 War, conflict
 Openness to multiculturalism, safe haven, destination country

Definitions

 Visible minority: people living in Canada who are non-Caucasian in race or non-white in colour
and who are not indigenous
 Diversity: differences among people reflecting many traits such as age, gender, country of origin,
and religion (also disability; diversity is constantly changing)
 Ethnicity: Groups that have a shared identity based on heritage, language, beliefs and values
(frequently used instead of race)
 Race: socially created categorizations of people based on skin colour or other biological
characteristics
 Racialization: the assignment of value or status to artificially create racial categories that
consequently result in inequalities at social, economic and political levels (cause inequalities at
these three levels, racialization is increasing)
 Multiculturalism: a societal value that encourages ethnocultural diversity and emphasizes the
freedom of all people to preserve, enhance and share their cultural heritage (Canada prides
itself in this)
 Sociological fact: refers to the presence of people coming from diverse backgrounds
 Prescriptive or ideologic: persistent ideas that say how to celebrate diversity
 Politically: government help sustain multiculturalism
 Immigrant: someone who is accepted in another country for the purpose of establishing
permanent residence
 Permanent resident: a person who has been granted permanent resident status in Canada has
been authorized to live and work in Canada indefinitely and has all the rights guaranteed under
the Canadian Charter or Rights and Freedoms, except the right to vote
 Three primary categories of permanent residents:

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 o Economic immigrants: people selected for their skills and ability to contribute to
Canada’s economy. Includes skilled workers, business immigrants, provincial or
territorial nominees, caregivers, and the Canadian Experience Class. Includes the
principle applicant and spouse/partner and/or dependents
o Family class immigrants: people who are sponsored by a Canadian citizen or permanent
resident living in Canada who is 18 years or older, includes spouses, partners,
dependent children, parents and grandparents
o Refugees: includes people who have had their refugee claims accepted while in Canada,
government assisted refugees who have had their claims accepted outside of Canada,
refugee dependents, privately sponsored refugees, and blended sponsorship refugees
 International students can apply for permanent residency if they have Canadian Experience
Class
 Temporary Residents: allowed to stay in Canada temporarily
o Temporary workers: work permit- federal program, skill level, skill type, often paid
poorly, no insurance, likely to be exploited, challenged more for WSIB claims, paid less
o International students: study permit
o Refugee Claimants: asylum-protected by a nation, can apply for permanent residency
o Valid documentation
 Undocumented Migrant: not authorized to be in Canada because work or study permit expired
or other reasons, or entered country illegally
 Migrant: a person who has moved from his or her country or region of origin either temporarily
or permanently
 Citizenship (ages 18+)

o Have permanent resident status o Language skills

o Have lived in Canada for 3 out of the o Pass a citizenship test
last 5 years o Other requirements may apply
o Filed taxes for at least 3 out of 5 years

Health after Migration to Canada

 Healthy immigrant effect: term given to the phenomena of immigrants arriving to Canada with
stronger health than their Canadian-born counterparts
 Access to health care/services may be limited
o Health after immigration may decline
o All permanent residents are eligible for publicly funded health insurance, as well as
temporary foreign workers and international students
o Waiting period until coverage begins
o Language barriers may prevent them from seeking care
o Lack of information to navigate healthcare system- don’t know where to go or who to
talk to
 Settlement services
o Assists immigrants and refugees adjust and orient to life in Canada
o Services may be limited due to restrictive funding
o Few services available to temporary workers or undocumented workers

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 Providing Nursing Care

 Nurses must recognize the diverse values and understanding of health within social and
economical contexts when providing care
 CNO and CNA promote respect for diversity
 Nurses must plan, implement and evaluate care that is socially just
o Complete this through advocating for social justice
o Assessment for social determinant of health in both socioeconomic and political context
 Advocating for proper employment environments
o Temporary workers: charged exorbitant recruitment fees, forced to work unpaid
overtime, subjected to dangerous working conditions, housed in sub-standard living
conditions
 Racialized people in Canada are significantly more likely to live in poverty
 In 2016 20.8% of people of colour are low-income, compared to 12.2% of non-racialized people
 Assessment
o Be aware of how you interpret or filter findings
o Be aware of the inherent power imbalance between nurse and patient
o Provide a holistic assessment, such as what health means to them and specific questions
related to their migration
o Use interpreters if needed
 Increasing linguistic diversity in Canada can present challenges to nursing care
when availability of translated health information or interpreters are limited
 Ensure you follow the guidelines for working with interpreters:
 Client must consent
 Attempt to identify things such as differences in dialect, religion,
political affiliation, gender, age and social status
 Family members or friends should be a last resort
 Emphasize confidentiality with interpreter and client
 Speak in simple terms
 Write down key points and get interpreter to look at it ahead of time
 Explain importance that the interpreter of repeating everything spoken
by client and nurse
 Talk to client, not interpreter
 Speak to interpreter in short simple sentences and have interpreter
relay after every sentence
 If you sense there is more being said than what interpreter is relaying,
ask interpreter to explain what is being said
 Ask client to repeat in own words what you have told them
 After the encounter, ask interpreter to share his or her perceptions,
especially if there was anything about the interaction that was difficult
to interpret
 Assessment questions should include:

o Tell me about how you came to

Canada

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o What was life like for you and
your family when you first
arrived
o What is life like for you now
o What has helped you settle in
Canada
o What life challenges are you
trying to manage right now
o What helps you stay healthy
o What prevents you from being
healthy
o Where do you go for health
care services? What have those
experiences been like for you

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 CNO and Providing Culturally Sensitive Care

 Providing culturally sensitive care is an important component of patient centred-care

 Avoid making assumptions just because a person is of a certain culture
 Nurses must strive to enhance their ability to provide patient-centered care by reflecting on how
their and the patient’s culture’s, values, and beliefs impact the nurse-patient relationship
 The nurse also must understand how bio-psychosocial needs and cultural background relate to
health care needs
 The nurse must acquire cultural knowledge and facilitate client choice
 The nurse must engage in therapeutic communication through:

o Interpreters o Non-verbal o Preserving and

communication integrating culture

Seeing Culture Relationally

 Culture is seen as dynamic and changing, both influence and being influenced by individuals,
groups and context
 A process that happens between people- a relational process
 Involved people selectively responding to and integrating particular historical, social, political,
economic, physical and linguistic structures and processes
 Involves 5 elements:
1. See culture contextually “what multiple contexts may be shaping culture”
2. Avoiding confusing and conflating culture with race, religion, ethnicity or nationality
3. Seeing culture as more than single group membership
4. Examining how culture is infused with power
5. More intentionally seeking to influence the cultures within which you work

Patient Centred Care: Vulnerability and Intersectionality

Definitions

 Health inequities: differences in health that are unfair/unjust

o Created by social conditions
o Amenable to change
o Not set in stone
 Health inequalities: uneven distribution of health or health resources as a result of genetic or
other factors or the lack of resources
o Can’t really change
 Health disparities: differences in health status among ethnic groups as a consequence of racism

Vulnerability

 Precarious conditions, marginalizing conditions, life circumstances

 Vulnerability means that there is a potential for harm to occur (doesn’t mean that they will
always be vulnerable)

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 Suggests that individuals or groups are in need, at risk of, or susceptible to harm because of
their exposure to a particular social condition
 Vulnerable populations: groups such as women, the poor, Indigenous people, immigrants,
elderly people, children living in disadvantaged circumstances and people with disabilities
 Can be someone confined to the hospital
 Disadvantaged, marginalized, priority, or vulnerable populations: used interchangeably and as
“catch all” terms that do not distinguish specific structural conditions that create disadvantage

Potential Conditions that shape vulnerability

 Illness (underlying condition and age) unhealthy, in a new environment, unable to fully care for
themselves, may have more than one health problem, pre-existing health conditions, previous
health issues could make them immunocompromised
 Racialization: different because of race, biases, system may not be built to accommodate them
 Poverty
 Inadequate housing or food
 Stigma
 Previous trauma
 Violence and abuse

Perspectives on vulnerability

 Individual perspective on vulnerability

o Conditions inside control
o Ex. “The homeless person is on the street because he does not work”
o Places blame on the individual for shortcomings
o Easier to place blame on individual than looking at the big picture as to why they are in
that state
 Social perspective on vulnerability
o Conditions outside of control- focuses on understanding distal factors
o Ex. “The homeless person is on the street because of declining social support, increasing
unemployment, and increasing cost of living”

A Relational Perspective

 When we think we see health inequities at the individual level, we are truly seeing combination
of many elements
 Do not intervene in relation to individual but also address structural problems at the contextual
and intrapersonal level

Social Determinants of Health

 Have a greater impact on a person’s life than actual lifestyle choices

 Materialistic explanations
o Income, housing employment, social support, education etc
o Control over these leads to better health

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 Neo-materialistic explanation
o Dynamics of unequal distribution of resources affect health
o Eg. Lack of affordable housing in Canada, minimum wage
 Life-course explanation
o Cumulative impact of social and economic conditions on health throughout the lifespan
o Eg. Diabetes in indigenous populations, due to poverty, traditional changes in diet
 Psychosocial explanation
o Stress associated with social positions affects health
o Stress directly affects health

Living Conditions Contributing to Vulnerability

 Poverty  No permanent housing, may be living in

 Not able to meet basic needs, food, unsheltered places, emergency shelters
water, housing etc.  More likely to die prematurely
 Indigenous, newcomers, people living  At risk for developing heat stroke, frost
with multiple illnesses, minimum wage bite
less than cost of living  Unsafe housing
 Physical and built environment  Infections
 Social networks, personal health  Food insecurity
behaviours, and their positive social  Children may be going to school hungry,
interactions, is their neighbourhood can affect their ability to learn, parents
safe will sometimes not eat so their children
 Housing can
 Housing insecurity is when someone is  Social exclusion
spending more than 30% of income on  Someone may be socially excluded
rent because of lack of unclean clothing,
 Cleanliness, mold, rats, cockroaches, unable to maintain hygiene, can affect
overcrowding their ability to gain employment
 Homelessness

Limitations with labeling vulnerability

 Moves responsibility toward the people experiencing the inequity and away from causal
conditions
 People may or may not identify themselves with a certain group
 May be labelled as low income, but they may not identify with that
 People may be outraged with labeling
 Need to be mindful of the effects of categorizing people
 Negative stereotypes/disease specific connotation
 Marginalization-different from the norm and therefore, are moved to periphery of society

Countering Individualizing Discourses

 When you hear “choice” ask “what is constraining and enabling choice for particular groups and
individuals?”

27
 When you hear “vulnerable” or “marginalized” ask “vulnerable/marginalized to/by what?” What
is creating vulnerability/marginalization?”
 Try alternative language such as: life circumstances, precarious conditions, marginalizing
conditions

Looking Upstream

 Nurses need to look upstream by looking at clients SDOH to determine potential causes of poor
health and root causes for vulnerability
 Participate in health care and society in ways that lessen inequalities
 Understand how we can provide care within the context of our clients’ lives
 Provide care that takes inequities and vulnerabilities into account
 Taking into account intersecting factors and poor health
o Multiple SDOH affect health

Intersectionality

 Exploring the intersections of race, gender, and class and their impact on individual well-being
has important implications for critically examining issues of justice and equity for marginalized
populations
 Intersectionality has previously been described as a perspective, concept, lens, theory, and a
paradigm; however, we have chosen to incorporate intersectionality as a paradigm in our
research as a way of thinking and understanding and acting as well as a method of analysis
 Influences come together in distinct ways and lead to distinct health outcomes for individual
groups, providing context to health experiences and drawing attention to the dynamic interplay
between different system levels

Role as a Nurse

 Use an intersectionality lens in practice (helps nurses attend to power dynamics)

 Use of intersectionality lens in research
 In addition to looking within, recognizing our own beliefs/values/stereotypes/assumptions etc.
and reflect on how they may be different from our clients, as well as recognizing how social
processes impact life circumstances
 Advocate for policies that address the SDOH
 Promote capacity and empowerment building with communities and individuals
 Include individuals in the discussions of change

Indigenous peoples and nursing

Indigenous peoples in Canada

 3 legally recognized Indigenous groups:  1.5 million Indigenous people in

Indian, Inuit and Metis people Canada, which make up 4.6%
 There is significant diversity among  From 2006-2016, the Indigenous
groups population grew by 42.5%, which
 Over 70 Aboriginal Languages means a significantly younger
 Over 600 reserves population

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 Lumping all indigenous categories government committed to chang the
together homogenizes people and their term to Aboriginal
views  Allows federal government control over
 Every culture has their own traditions, Indian status, land, resources, wills,
opinions, beliefs, views etc education, band administration, health
 Ask the person, “is there anything I can care
do or anyone I can call?”  Treaty agreements outlining promises,
 Reserves on poor environmental obligations, and benefits for both
grounds, are crowded, poverty parties
 Indian is the legal term in the Indian Act  Non-status is someone who is not
established 1876, in 2015 the federal registered with the federal government
under their regulations

 With reserves being so far from the main centres, considerations need to be made for patients
in regards to

o Community/travel nursing o Travelling

o Discharging o Culture shock
o Plan of care o Evacuees

Inuit of Canada

 Founding people of what is now Canada  They consider land, water and ice their
 Occupied across the arctic homeland to be integral to their culture
 Four regions known as Intuit Nunangat and way of life
 Roughly 60,000 Inuit people in Canada  Suicide rates are 11 times higher in Inuit
people and 40 times higher in Inuit men

Metis of Canada

 Descendent of Indian and European o Accepted by the Metis Nation

marriages  Roughly 600,000 Metis peoples in
 A Metis person: Canada
o Self identifies as Metis  Majority live in western provinces and
o Has historic Metis nation Ontario
ancestry

Treaties

 Treaties were alliances that established relationships and were used long before Europeans
arrived
 Included trade, safe passage through territories, peace and friendship, and other obligations and
responsibilities
 Establish peace, regulate trade, share land and resources, and arrange mutual defense
 Europeans had a different meaning of treaties: it served to recognize independence, claim
sovereignty, and formally marked mutual respect
 A significant document between the Indigenous peoples and European settlers

29
 Permitted Indigenous and non-Indigenous people to divide and share sovereignty rights to the
lands of Canada
 In 1867 the first confederal agreement with the First Nations would allow for power sharing
among diverse peoples and governments
 In 1982, Section 35 of the Constitution Act, states the existing aboriginal and treaty rights of the
aboriginal peoples of Canada are recognized and affirmed and the aboriginal peoples of Canada
includes the Indian, Inuit and Metis peoples of Canada

Language and Geographical Territories

 Traditional territory refers to the geographic area including land, water, and ice identified by a
First Nations, Inuit or Metis community in which their ancestors resided
 Indigenous people stance with the land was to live in harmony with it as it provided their
livelihood and sustenance
 The Europeans attitudes were land ownership prevailed along with the expectation of exploiting
the land’s natural resources.

Colonization and Assimilation

 Colonization in the 1800’s resulted in many treaties that were undermined by policies and
practices that intended to remove Indigenous peoples from their lands, suppress nations and
government, and undermine culture and identity
 Indian act, residential schools, relocations of communities and reserve policies created
assimilation
 Assimilation is the social process of absorbing one cultural group into another
 Aggressive cultural domination
 Through colonization, the heath, mental health, socio-economic and politics of Indigenous
communities have been greatly affected

Residential Institutions

 Officially began in 1879, but actually began much earlier

 First residential school was in the 1620’s where Quebec city now lies
 Last residential school closed in 1996 in Saskatchewan
 Our Federal government used residential schools to assimilate Indigenous peoples
o Cultural genocide
o Not schools- but institutions
 In 1874, our Canadian government removed children from families and communities, and
placed them in residential schools
o Forbidden to speak their language resulting in a loss of language
o Forbidden to practice their cultural traditions resulting in suppression of spiritual and
cultural beliefs and loss of identity
o Physical and sexual abuse by clergy
o Forbidden family visits which resulted in disruption of families
 John A. MacDonald- Canada’s first prime minister also held the role of Minister of Indian Affairs

30
 In 1879, he sent Nicholas Darwin to Washington D.C. to learn about the policy of “aggressive
civilization” which was implemented in the US through “Industrial Schools” where religious
instruction and skills were combined.
 His goal was to “kill the Indian in the child”
 Goals of Canada’s Aboriginal policy were to eliminate Aboriginal governments, terminate
treaties, and assimilate Aboriginal people and cause them to cease to exist as distinct legal,
social, cultural, religious, and racial entities and destroy their culture
 It left intergenerational suffering, pain and trauma

Sixties scoop

 In the 1950’s the government began phasing out compulsory residential school education as
people began to see the devastating impact
 People recognized that public education would be more beneficial
 In 1951, an amendment was made to enable the Province to provide services to Aboriginal
people where none existed federally- child protection services was one of these areas
 No qualifications for social workers- they began forcefully removing aboriginal children from
their homes and brought them to residential institutions or fostered them to non-aboriginal
families
 Children were denied their ancestry and were told they were Italian or French

Historical Trauma

 Cumulative emotional and psychological abuse over the lifespan and across generations as a
result of colonization and attempted genocide resulted in loss of:

o Culture o Parenting o Autonomy

o Language skills and self-
o Heritage o Land and determinatio
o Identity livelihood n

Kitimakisowin

 Cree word describing the devastating effects of colonization

 Five areas:

o Poverty due to marginalization o Poverty of subsistence due to

o Poverty of understanding due to inadequate resources
poor education o Poverty of identity due to alien
o Poverty of affection due to lack of values and beliefs
support and recognition

Determinants of Health for Indigenous People

 Determinants of health are generally poorer among Indigenous people

o Physical and social o Socio-economic status

environments (income), poverty
o Access to quality health care o Food insecurity

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 Aboriginal people living off reserve have better access to care and health environments
 Systematic racism, colonialism, and poverty are key factors in determining health of Indigenous
peoples
 Life expectancy is 7 times shorter than rest of Canadian population
 As a nurse, it is important that we integrate the cultural traditions of our individual clients

o Our- knowledge, attitudes, beliefs, values

o Their- through art, ceremonies, songs, stories, food
o Our- Inviting elders and healers
o Their- speaking own language

 The poorer determinants of health result in:

o Lower life expectancy o Higher unemployment rates

o Higher infant mortality o Higher rates of suicide
o Lower income and education o Higher rates of chronic disease
levels

Strengths of Indigenous People

 Resistance: resisting the assimilation by using problem-solving behaviours

 Resilience: positive adaptions to life despite horrible conditions of colonization
 Reclaiming: reclaiming identity, language and culture

Health Services

 Under the Healthcare Act, access to Healthcare is defined as “the equitable distribution of
services to those in need for the common good and health”
 Persistent inequalities in health status and access to health care services for Indigenous peoples
are serious issues as Indigenous peoples face significant barrier to achieve equitable access
 Jordan’s principle (named after Jordan River Anderson, a child from Norway House Cree Nation):
payment disputes within and between federal and provincial governments over services for First
nations children are not uncommon and children are often left waiting for services they need or
denied services that are available to other children. Parent or child requires status
 Non-insured health benefit: coverage based on eligibility to pay for specified medications, dental
care, vision care, medical supplies and equipment, short term crisis intervention, mental health
counselling and medical transportation
 It is a slow process, covers the lowest standard of care, often results in delays of treatment while
waiting for funding approval
 Colonization has resulted in complex arrangements for jurisdiction, administration and
governance over health care
 Federal government has jurisdiction over primary health care services for those in First Nation
and Inuit communities
 Responsibility for providing health care to the majority of Indigenous peoples (~70%) is held by
provinces and territories
 76 Nursing stations and 195 health centres serving over 600 First nation communities
 Health Canada provides nursing services in rural, remote, and isolated First Nation communities

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 Nursing stations are available in remote (fly-in) communities
o Primary care, public health, emergency care, prep for medical evacuation
o Advanced practice nurses or nurses with additional training run these, physicians attend
on a scheduled basis
 Health centres area available in rural (drive to) communities
o Health promotion, illness prevention and health protection
 Health services transfer process
o Funding agreements with Health Canada that communities oversee health services

Nursing Care and First Nations, Inuit and Metis people

 The following issues related to respect have been of concern to both nurses and patients
o Disrespect, prejudice, and discrimination
o Health care providers not considering the patient’s perspective
o Not providing sufficient privacy
o Inadequate explanations for medical or nursing procedures and results
o Not establishing clear and informed consent
o Use of a harsh or condescending tone with Elders, patients, or family members
 This leaves clients feeling misunderstood, unaccepted, and lessened as individuals through
verbal and nonverbal communications by staff
 Ways care for First Nations, Inuit and Metis people:

o use a decolonizing filter o engage in sharing circle and

o examine your own beliefs and cultural immersion practices
assumptions of indigenous o foster equity in care
people o advocate for organization
o provide non-judgemental, non- policies that are not
discriminatory care to discriminatory
Indigenous clients o provide care that integrates the
o educate yourself of First clients cultures and beliefs
Nations, Inuit and Metis o address the SDOH with your
peoples history and culture clients
o attend workshops on trauma- o engage in intercultural
informed care and cultural communication
safety courses o build authentic relationships
with Indigenous peoples

Spirituality and Nursing

Spirituality and Health

 Spirituality: complex, persons beliefs, perceptions of meaning of life and death, greater power,
integral part of health and shapes life's journey.
o It is questions of their current state, Why is this happening now, is there an afterlife, Can
I resolve my issues with others before I pass.
 Religion: Organized system of beliefs

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 o Affiliations, rights, and rituals based on communal practices and codes of conduct.
 Worldviews: mental maps that explain the world around us
 Spiritual dimensions of health
o May or ay not involve a connection to a divine presence or religion
o Involves spiritual strengths that affect many parts of a person

 Physical  Cultural
 Mental  Relational
 Emotional

o Ability to develop a purpose in life.

 Relates to nurturing strengths and positive states
o Application to healing and coping.
 Enhances coping, resilience, compassion, longevity

Why consider spirituality in Healthcare

 Spirituality intertwined with health leads to a trend in positive outcomes

 Not addressing spirituality is not addressing holistic health
 Nurses spend most time with patients, so they are in the best position to discuss spirituality

Spirituality in Nursing

 The health and healing is well documented, but nurses continue to identify several challenges in
integrating spirituality into their practice, such as lack of support or fear
o Lack of time to address spiritual aspect
o Focus on nursing practices are technical not spiritual
o Nurse may have discomfort addressing spiritual aspect as beliefs may differ or they do
not want to be intrusive
 Nurses can address challenges by:

o Exploring their concerns o Following guidelines on spiritual

o Educating self on spiritual care
practices o Assess of applicability for
referrals to spiritual care

 Nurses’ role:
o Inclusive spiritual care

 Provide relevant and non intrusive care

 On our diverse spiritual views and cultural views
 Help explore an mobilized factors to support healing

o Rely on the patient as a guide/ leader

o Insurance tickle inquiry and follow up
 Spiritual care is a patient right
 Such care can be defined by the patient
o Providing verbal and nonverbal spiritual care

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  Noticing cues from patient
 Listening attentively and empathetically
 Using appropriate touch
o Developing unconditional presence
 Involved a deeply authentic, connectedness

Spirituality and Nursing

 Establish relevance with your client

o “As part of your care, we would like to be aware of anything you consider to be
important in relation to the spiritual aspects of your life."
o “So how might we, as nurses attend to and care for your spirit?”
 Initial questions
o Do you have affiliation with any spiritual, religious or cultural traditions?
 What are these?
 Can we integrate them into your care?
o Are there any unresolved issues you would like support in exploring at this time?
 Allowing client to communicate their suffering
o Why is this happening to me?
o Am I being punished?
o How can I carry on like this?
o Who will Remember Me when I'm gone?
o Is there an afterlife?

TRUST Model

 Traditions and practices  Searching

 Reconciliation  Teachers
 Understanding

 Using the nursing process To identify spiritual needs

o Spiritual distress related to unmet spiritual needs arising from current health crisis, as
evidenced by patient verbalizing feelings of hopelessness
 Using the nursing process to identify spiritual strengths
o Readiness for enhanced spiritual well-being related to health care incongruent with
personal spiritual need, as evidenced by patient desire to receive spiritual care

Nursing Theory

Concept

 Idea or notion that represents some aspect of personal/ human experience

 Not concrete, can change overtime
 Important in that they serve as the building blocks of theory

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 Nurses use concepts to understand and/or describe situations and circumstances
 Not universally understood
 Meaning of concept can be different to different people

Theory

 Comprises several concepts used to describe, explained, or make predictions about a

phenomenon
 A model is a visual representation of a theory, which may include graphics or symbols,
demonstrating the relationships between concepts.
 Body of knowledge created through research, supports or helps refine theory
 A theory can be tested. Is it right? Does it reflect reality? Does it accurately describe, explained,
or predict what we are concerned about?
 Research process is used to test theory.

Use of theory in knowledge development

 More than just something to memorize... Very much a Part and intertwined in nursing practice.
 Nurses engage in direct client care, education, administration, and research using theory,
comment and importantly, these practice areas inform theory development.

Assumptions of Nightingale’s Practice Approach to Care

 Based on the collection and analysis of data about morbidity and mortality, Nightingale posited
four theoretical assumptions about nursing and health care.
o The nursing client relationship is important
o The environment has a direct effect on the clients well being
o Environmental factors such as fresh air, pure water, cleanliness of the client and
environment, and late exposure contribute to good health and recovery. The absence or
diminishment of these factors can contribute to illness and poor health
o And nurse can determine interventions necessary to modify the environment and influence
positive client outcomes
 She found that military hospitals were infested with bugs and unhygienic.
 Environment factors had a huge impact on the theories she proposed
 2/3 of death rate improved due to her theories
 Generator of new nursing knowledge
 Leading us in the statistics world of nursing
 Showed statistically how data improved once her practices were put in place.

Metaparadigm

 Describes a global framework or away a professional discipline Views the world

 How individual professions view how they view
 It is the most general statement of a discipline
 The primary concepts that are of interest, unimportance to a profession are described by the
metaparadigm.

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 Person:
o Individual, family, social, environmental, spiritual factors, we live in a context of
systems. (ie. Families, marriage, communities.)
 Health
o Subjective, individualized, many interpretations
o Physical, mental, socioeconomical, relative concept, can shift over a life span.
 Environment
o Internal and external contexts impact someone's health.
 Nursing
o Care provided to individuals regardless of who they are
o Profoundly relation of
o Individuals are considered as experts in their own health.

Nursing Theories

 Specific to nursing
 Represent the body of knowledge for that practice
 Nursing theory represents the body of knowledge that is used to describe or explain various
concepts found in nursing practice
 Types:
o Grand nursing theories (highly abstract)- eg theories proposed by Florence Nightengale
and Jean Watson
 Can’t be tested directly
o Midrange (narrower in scope) – eg. Nola Pender’s Health Promotion Model
 Bridge between grand nursing and nursing practice theories
 Emerge at intersection of research and practice
o Nursing practice theories (developed to use within specific nursing care situations)
 Provide framework for nursing interjections

Strength Based Care: Theory

 Strength based care represents a theory that introduced a new way of thinking in nursing.
(Moving nursing away from a deficit model of care) that had/ has implications for practice and
nursing interventions
 Strength based care looks at a person or family strengths as the unique qualities and resources
that comprise their personhood
 Strengths are needed to meet goals, improve health., restore wholeness, overcome challenges,
and improved quality of life

Theories Used in Nursing

 To provide an example of an imported theory used to develop one that is nursing specific, a
nurse can look to Patricia Benner's from novice to expert.
 Nurses develop their own body of knowledge.

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 How Nursing Theory Supports a Nursing Standpoint

 Nursing and nursing knowledge can make a profound difference to patient/ family well-being,
nurse well-being and system well-being.
 Nursing theory can help develop a nursing orientation through which to focus your attention,
inquire, interpret, an act as you would go about your nursing work.

Theoretical considerations

 What values are embedded within the  How does this theory define the focus
theory? and purpose of nursing?
 How does this theory conceptualize  What does it take for granted? Or
people? assume about people, health,
 How does this theory conceptualize environments, and/ or nursing?
health?  What does it fail to address?
 How is environment conceptualised and  How might it inform your practice?
incorporated?

Paterson and Zderad’s Humanistic Nursing Theory

 Builds on Pepau’s (1952) Work on interpersonal experiences between nurses and patients
 Describes nursing as “an experience lived between human beings”- move beyond “doing” to
“being”
 Humanistic nursing is happening between people
 Intersubjective - the space between when two or more people come together- between
subjective and objective.
 Humanistic nursing promotes the “more being” of people.
 Characteristics. (being with an doing with; Dialogue; Here and now, occurring in situations, all at
once, complementary synthesis.)

Characteristics of Humanistic Nursing

1. Nursing as being with and doing with 4. Nursing in situations

2. Nursing's dialogue 5. Nursing all at once
3. Nursing as here and now 6. Nursing as complementary synthesis

Theorizing your own Nursing Practice

 Pragmatically determine what a particular concept or theory leads you to focus on, to attend to,
and to do in your own nursing practice, period. Looking at theory pragmatically, you are called
to determine the concrete difference that theory makes in nursing practice

o How would I enter nursing o How would I relate to myself

situations differently? and context in which I work
o How would I see and relate to differently?
people differently? o What is the value of the theory
o What matters most? in experiential terms?

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 Ways of Knowing

Fundamental Patterns of Knowing

Personal Knowing

 Process of self knowing next line in your experience when you become whole as a person
becoming your genuine self, know who you are in relation to others
 Who you are as a person affects your behavior, attitudes, and values both positively and
negatively.
 Develops from interactions and relationships
 Process of reflection in order to understand how your feelings may affect your nursing care
 Understand yourself to increase your authenticity, as in herself grows, authenticity grows.
 Why is it important in nursing?
o Assists in building therapeutic relationships
o Assists in minimizing biases that interfere with caring for patients

Example: is operating when you Luella, an older nurse-midwife, recognizes that she has strong negative
feelings about young, single, itinerant mothers that she must contain. Raised in a loyal religious family
with conservative political Values, Luella is in touch with the source of her negativity and tries to channel
it into accepting an understanding the perspective and situation of her young female clients.

Ethical knowing

 Ethics in nursing is focused on matters of obligation: what ought to be done

 Goes beyond knowledge of the norms or ethical codes of conduct: an involves making moment
to moment judgments about what ought to be done, what is good and right, and what is
responsible
 Ethical mowing guides and directs how nurses morally behave in their practices, what they
select as being important, where their loyalties are placed, and what priorities demand
advocacy.
 Ethical dilemmas are between two situations: which is the right one to choose?
 Involves clarifying conflicting values and exploring alternatives
 May be no satisfactory answer to ethical dilemma or moral stress
 Requires experiential knowledge of social values
 Ethical principles/codes provide insight
 Ethical knowledge does not prescribe what a situation action should be; direct you to what
would be sound, ethical and just

Example: Ethical knowing comes into play when Leena, a nurse working in rehabilitation, learns that a
young man in his care travels across state lines to purchase marijuana legally for medical use and then
uses it for pain control in his state, where marijuana is illegal. Leena must decide whether to ignore what
he has learned or to share this knowledge with others and run the risk that his patient’s pain will not be
properly controlled.

Aesthetic knowing

 Art of nursing

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  An appreciation of the meaning of a situation and calls forth inner resources that transform
experience into what is not yet real, thus manifesting something that would not otherwise, be
possible
 Allows us to connect with human experiences that are unique for each person
 Evokes a response that is transformative
 Entails drawing on experiences and health/ illness; Drawing from different ways of knowing
 Looking for creative ways to connect with someone and know them.
 Aesthetic knowledge means:
o Grasping meaning of an encounter
o Establishing connection.
 Performing in moral an appropriate way
 It is often spontaneous, in the moment, intuitive
 Helps us know how to deal with circumstances that are unique and unpredictable
 Helps us to grow through reflection

Example: Otto works in the orthopedic clinic of a large urban hospital and uses aesthetic knowing with
each young child who comes in for cash removal. It is aesthetic knowing that helps him remove the cast
in the least distressing way for the child. Otto understands that this child likely sees a large person
approaching her leg with an electric cutter and other tools that resemble those in her father's
woodworking shop. Otto might use a combination of distraction in humor as well as careful timing to
move through the required procedure in an artful way.

Empirical ways of knowing

 Empirics assumes that what is known is inaccessible through the physical senses
 Grounded in science and other empirically based methodologies (logical reasoning/ systematic
models including testing hypothesis, generating theory, describing phenomena)
 Assumes that an objective really exists
 Truths can be understood through inferences based on observation and understandings that are
verifiable

Example: Maria as a new graduate nurse working in an acute care facility, uses empirical
knowing by reviewing the procedure, important considerations, and hospital policy on catheter
insertion prior to completing the skill.

Emancipatory knowing

 Human capacity to be aware of and critically reflect on the social, cultural, and political status
quo, and to determine how and why it came to be that way.
 Emancipatory knowing calls forth action in ways that reduce or eliminate inequality and injustice
 Examining relations of power-Dominance of certain ideologies, beliefs, values, or views of the
world over other possible viewpoints
 Questions
o What are the barriers to equality?
o What changes need to be made?
o Who benefits?

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 o What is wrong in this picture?
 Why is this important in nursing?
o Identifies barriers that prevent health and well-being for all people
o Determines what is wrong and what sustains injustices

Example: Emancipatory knowing occurs when Benjamin, a nurse practitioner in a Wellness clinic,
becomes aware of the extent to which overweight children are seen in her practice. Emancipatory
knowing would focus on understanding the social and political processes that have contributed greatly
to the problem of childhood obesity, such as understanding how lack of regulation of the food industry
with regard to labeling or use of harmful food ingredients is linked to capitalistic profit motives for large
corporations that market to children. These understandings might lead Benjamin to organize a group of
parents to lobby legislators to pass legislation banning the use of harmful food ingredients that
contribute to obesity.

All the Ways of Knowing in Nursing

 Allow us to:
o Understand ourselves and nursing practice at a much deeper level.
o Appreciate nursing as both an art and a science
 Praxis (fancy word for practice)

o An integrated expression of emancipatory knowing.

o When all patterns are integrated in a way that supports social justice
o Praxis at the individual level when people reflect on unjust situations with a growing
realization that things could be different and take action to change the circumstances of
their own and others lives.

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