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This toolkit consists of a six-step framework to assist you when working to resolve a professional practice issue in any context of practice. Tools to help you communicate your concerns related to the professional practice issue with all members of the team including your manager are also part of this toolkit.

Please note: 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. If you require assistance when working to resolve  a professional practice issue, do not hesitate to contact a Practice Consultant at CRNNS for support by emailing practice@crnns.ca or calling 902.491.9744 (toll free: 1.800.565.9744).


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STEP 1: Identify the Professional Practice Issue

The first step in addressing a PPI is being able to identify the issue. As previously stated, a PPI is an issue that compromises client care/service by placing a client at risk or affects a nurse’s ability to provide care/service consistent with the Standards of Practice for Registered Nurses, Code of Ethics, other standards and guidelines, or agency policies or procedures.

In order to determine if your issue is a PPI, you can ask yourself the following questions:

  • Does the issue present a risk to clients?
  • Does the issue make it difficult to practice according to the Standards of Practice for Registered Nurses and/or Nurse Practitioners Standards of Practice, the CNA Code of Ethics, Acts or other legislation governing nursing practice?
  • Does the issue conflict with the organization’s standards, guidelines, and/or policies?

If you answered “yes” to any of these questions, you may have a professional practice issue. If you answered “no”, your issue is not likely a professional practice issue but still needs to be explored further and resolved.

Professional Practice Issue Examples:

  • Inappropriate use of social media such as friending or discussing clients on Facebook
  • An RN from OBS being floated to ICU and being assigned a ventilated patient without appropriate support
  • Withholding critical information about a client from the care team
  • Inaccurate or missed documentation about a client

STEP 2: Explore the Issue and Define how Client Care and/or Service is Affected

Taking the time to fully explore a PPI will help you to gain additional insight and a shared understanding among members of the healthcare team. This can also help prevent a quick response that could be influenced by incomplete information, personal emotions or assumptions.

Reflecting on a PPI is one way to look at the situation more objectively and can help to identify the root cause(s). Gaining your teams’ perspective can provide further clarity about the issue and support a team approach. The following questions have been designed to assist you to reflect on and explore a PPI in greater detail.

  1. What makes this a PPI? For example, how does this issue:
    • Place clients at risk?
    • Affect your ability to practise according to CRNNS’ nursing standards of practice and CNA 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?
  4. Who is affected by the PPI and what are their perspectives?
  5. Does your organizational policies, procedures, or guidelines contribute to this issue?
  6. Is this a recurring PPI? And if so, why is it recurring?

Once you have explored the PPI fully, develop a detailed description of the issue. Include the date, time, place, people involved and a description of how the issue affects the client, your nursing practice and/or the team. Be sure to outline the contributing factor(s) (see chart below). This description will be helpful when communicating the issue with your manager and others.

Common Contributing Factors could include:

  • Competency
  • Accountability
  • Physical Resources
  • Responsibility
  • Communication
  • Human Resources
  • Standards
  • Policies/Procedures
  • Legal/Ethical

STEP 3: Identify Resources

Now that you have a good understanding of the PPI, the next step is to identify resources that could be helpful as you work to resolve the issue. These resources can be internal or external to the organization.

These are examples of resources that could provide support or information.

INTERNAL SUPPORTS

  • Colleagues
  • Managers
  • A mentor
  • Other Health Professionals
  • Human Resources
  • Clinical Educators

EXTERNAL SUPPORTS TO ORGANIZATION

  • CRNNS Practice Consultants
  • Union
  • Education Programs
  • Canadian Nurses Protective Society
  • Employee Assistance Program (EAP)
  • Human Rights Commission

RESOURCE DOCUMENTS

  • Standards of Practice and other CRNNS documents
  • RN Act
  • Agency policies and procedures
  • Code of Ethics

This is not a complete list. The resources you use will depend on the PPI you are addressing, what is available to you and personal choice.

STEP 4: Take Action

A planned approach is helpful, especially if your PPI involves many people or is challenging to resolve. When forming a plan of action, the following steps can be applied. Either individually or with the team:

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

The actions you take will depend on the PPI you are facing, the level of support from your team and the resources you have available to you.

Whatever action you choose, it is important to let your manager know so that they are aware and can provide support if required.

When discussing a PPI with your manager:

  • Provide an objective and detailed description of the PPI with the information identified in Step 2. Include how the PPI has impacted client care, safe nursing practice and/or team relations.
  • Frame conversations using the standards of practice and code of ethics. These documents focus the conversation on the nurses’ professional responsibilities, keeping the conversation more objective.
  • Bring possible solutions that could assist in resolving the PPI to discuss.
  • Identify what you could do to support the resolution of the PPI.
  • Follow up on the meeting with a written letter, stressing the importance of the PPI and indicating a reasonable date when you hope to hear back from the manager.
  • If a concern is identified with a colleague’s practice, attempt to discuss and resolve it with the individual involved. If you do not feel comfortable to have this conversation, or if practice is unchanged after having the conversation, you should consider involving the manager.

STEP 5: Document

It is important to keep personal records of all steps taken to resolve a PPI. This ensures there is an accurate account of events and that you are able to demonstrate you have met your professional obligations. It is recommended that all communication with managers and other leaders of your organization be noted in your personal records and any discussions or meetings be followed up with a written letter to them as soon as possible, requesting a written response by a specific date. A template that you can use to develop a letter can be found at Appendix A.

The CRNNS Duty to Report document provides further information about the legal and ethical responsibilities relating to reporting and documenting challenging situations in practice. The document clarifies the nurse’s legal and ethical obligation to report incompetent, unethical or impaired practice of a nurse or unethical conduct by any health professional to management, administration and/or the appropriate regulatory body.

Be sure to include the following in any written communication:

  1. The PPI description (step 2)
  2. When the issue occurred (specific date and time)
  3. Exactly what happened in an objective and factual manner
  4. How the issue has impacted on your ability to meet Standards of Practice, Code of Ethics or organizational policies
  5. Any other relevant information
  6. A request for the manager to follow up with you

Documentation is a tool to describe the status of a client or the care or services given to that client (Perry, A.G., Potter, P.A., 2010). The client chart is not the place to document discussions regarding a PPI but if the PPI has had a direct impact on the client, this should be documented. You may also be required to document the PPI in an adverse event monitoring system. Check your organization’s policies regarding documentation and/or refer to the CRNNS Documentation Guide for Registered Nurses for more information regarding principles of documentation.

STEP 6: Evaluate

The final step is to evaluate if the PPI has been resolved and how your actions have impacted on the issue. If the PPI was addressed with the support of others, it is important to include them in the evaluation process. An evaluation helps ensure the issue has been addressed and is a way to examine what you would do the same or change in the event that another PPI were to occur. Depending on the issue, it may not be possible to resolve it immediately and this should be considered in the evaluation process.

If the manager decides that it is best for them to manage the PPI, it is acceptable to ask the manager to inform you when it has been addressed. Be aware that because of confidentiality, the manager may not be able to provide you with detailed information about how they have resolved the PPI. They may only be able to inform you that the issue has been addressed. If you see the PPI reoccur in the future, it is important to let your manager know.

If when you evaluate, you determine the PPI has not been resolved, take a step back and consider why. Review the process you used by asking yourself the following:

  • Did you clearly identify the issue?
  • Could you define how and when client care or service was affected?
  • Were the right people involved in the discussions and attempts to resolve the issue?
  • Is there evidence that your manager took steps to address the PPI?
  • What could have been done differently?

Once you have done this, choose your next steps. If the PPI persists you need to continue to take action until it is addressed. Further action could include:

  • Request a meeting if you have not yet had a meeting with your manager.
  • Meet with your manager again to determine when resolution is likely if you have already met with your manager and the PPI persists.
  • Consider discussing the PPI with the next level of management in your agency.
  • Continue to notify the appropriate people until the issue has been resolved (Appendix B).
  • Review the Duty to Report document and/or contact a CRNNS Practice Consultant for guidance.

The PPI Toolkit provides a framework to support nurses as they resolve PPIs that occur in their practice. By addressing PPI’s, nurses ensure safe, competent, compassionate and ethical practice and the trust that the public holds for the nursing profession.

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