PR ACTICE STANDARD

Ethics

Table of Contents

Introduction 3
Why an ethical framework? 3

A starting point 3

Definitions 3

Ethical Values 4

Types of ethical concerns 4

Resolving ethical conflicts 5

Document layout 5

Client well-being 5

Client choice 6

Privacy and confidentiality 7

Respect for life 8

Maintaining commitments 9

Maintaining commitments to clients 9

Maintaining commitments to oneself 9

Maintaining commitments to nursing colleagues 10

Maintaining commitments to the nursing profession 11

Maintaining commitments to team members/colleagues 12

Maintaining commitments to quality practice settings 12

Continued on next page

Table of Contents continued

Truthfulness 13

Fairness 14

Working Through Ethical Situations in Nursing Practice 14

Assessment/description of situation 15

Plan/approach 15

Implementation/action 15

Evaluation/outcome 15

Conclusion 18

Selected Bibliography 19

VISION
Leading in regulatory excellence

MISSION
Regulating nursing in the public interest

Ethics Pub. No. 41034

ISBN 978-1-77116-125-1
Copyright © College of Nurses of Ontario, 2019.
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document may be reproduced in part or in whole for personal or educational use without permission, provided that:
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• The reproduction is not represented as an official version of the materials reproduced, nor as having been made in affiliation with,
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First published March 1999 as Ethical Framework (ISBN 0-921127-65-0)
Reprinted January 2000, October 2000, October 2002, Revised for Web June 2003, Reprinted January 2004, December 2005, May 2008.
Updated June 2009. Updated December 2018 to remove references to retired practice guideline, Disagreeing with the plan of care
Updated April 2019 for references to Child, Youth and Family Services Act, 2017.
Additional copies of this document may be obtained by contacting CNO’s Customer Service Centre at 416 928-0900
or toll-free in Canada at 1 800 387-5526.
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Ce fascicule existe en français sous le titre : Déontologie infirmière, n° 51034
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Nursing standards are expectations that contribute ethics, and they require the ability to think through
to public protection. They inform nurses of their a problem and reach a sound decision that they can
accountabilities and the public of what to expect of explain and justify by referring to ethical values.
nurses. Standards apply to all nurses regardless of their
roles, job description or areas of practice. This document is not intended to be a comprehensive
— College of Nurses of Ontario guide in nursing ethics. For more in-depth or specific
information, nurses are encouraged to consult with
Introduction colleagues and persons with expertise in ethics, and
to make use of the selected bibliography at the end
Why an ethical framework? of this document. Nurses may also want to enrol in
Consideration of ethical issues is an essential courses in bioethics or health care ethics. In Ontario,
component of providing care within the therapeutic all universities and many community colleges offer
nurse-client relationship. Nurses1 encounter such courses. Contact the continuing education,
ethical conflict, uncertainty and distress in their philosophy or nursing departments for information.
everyday practice. Continuous changes in the Nurses are also encouraged to attend conferences and
health care system, in areas such as technology and become involved in ethics committees and rounds in
in values, contribute to these ethical dilemmas. their settings to continue learning about ethics.
Understanding and communicating beliefs and
values helps nurses to prevent ethical conflicts and Definitions
to work through them when they do occur. There Nursing: Nursing is the therapeutic relationship
are many ways to understand and work through that enables the client to attain, maintain or regain
ethical situations. optimal function by promoting the client’s health
through assessing, providing care for and treating
A starting point the client’s health conditions. This is achieved
This document describes the ethical values that by supportive, preventive, therapeutic, palliative
are most important to the nursing profession and rehabilitative means. The relationship with
in Ontario. It also provides scenarios of ethical an individual client may be a direct practice role
situations in which there is a conflict of values. or it may be indirect, by means of management,
Nurses are encouraged to use these scenarios for education or research roles.
reflection and discussion. No solutions are offered
because there is no one solution that is best in all Therapeutic relationship: The therapeutic
situations. The behavioural directives are intended relationship is established and maintained by
to help nurses work through ethical situations and the nurse through the nurse’s use of professional
provide information about the College of Nurses nursing knowledge, skill, and caring attitudes
of Ontario’s (CNO’s) expectations for ethical and behaviours to provide nursing services that
conduct. These are taken into account when CNO contribute to the client’s health and well-being. The
Committees assess nurses’ practices. Nurses need relationship is based on trust, respect and intimacy
to consider behavioural directives carefully when and requires the appropriate use of the power
making decisions about ethical care as this process inherent in the care provider’s role. (For further
will strengthen their practice. information, see CNO’s Therapeutic Nurse-Client
Relationship, Revised 2006 practice standard.)
To make decisions about ethical situations, nurses
need to be aware of their personal values. They Caring: In the literature, caring is defined in
need to be knowledgeable of clinical situations and a number of different ways (Fry, 1994). Caring

1
In this document, nurse refers to a Registered Practical Nurse (RPN), Registered Nurse (RN) and Nurse Practitioner (NP).

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can be considered the behaviours, actions and Ethical Values

attributes of nurses. Caring nurses listen to and are CNO has identified the following values as being
empathetic with clients’ points of views. Generally, most important in providing nursing care in
caring requires the recognition of clients as unique Ontario:
individuals whose goals nurses facilitate. Clients’ ■client well-being;
values and choices are of primary consideration ■client choice;
when planning and providing care, and a nurse’s ■privacy and confidentiality;
own personal values must never interfere with the ■respect for life;
clients’ right to receive care. ■maintaining commitments;
■truthfulness; and
Client: A client is a person or persons with whom ■fairness.
the nurse is engaged in a professional therapeutic
relationship. In most circumstances, the client These values are shared by society and upheld
is an individual but in some circumstances (for by law. They are not listed in order of priority,
example, in practice settings where family-centred although it is recognized that client well-being and
care occurs) the client can include family members client choice are primary values.
and/or substitute decision-makers of the individual
client. The client may also be a family, a group (for Types of ethical concerns
example, therapy) or a community (for example, When two or more ethical values apply to a
public health). In education, the client may be a situation, but these values support diverging courses
student; in administration, the client may be staff; of action, an ethical conflict or dilemma exists.
and in research, the client is a subject or a participant Nurses may experience ethical uncertainty when
(RNABC, 1998). Regardless of the role, whether faced with a situation in which they are unsure of
directly or indirectly involved with individual clients, what values apply or even where the moral problem
all nurses are responsible for providing ethical care or is. They may also experience ethical distress when
service within CNO standards. they know the “right” thing to do, but various
constraints make doing the “right” thing difficult
Health care team: Health care, including nursing (Jameton, 1984).
care, is usually provided within the context of an
interprofessional health care team. The individuals in Not all nurses experience the same situation in
the health care team are either directly or indirectly the same way, and a situation that causes conflict,
involved in the client’s care. Depending on the uncertainty or distress for some nurses may be
setting, the composition of the team will vary. The straightforward for others. There is room for
team includes the client or substitute decision-maker, disagreement among nurses on how they weigh the
and the client’s family and/or significant other(s). different ethical values. But above all, nurses need
to choose ethical interventions that meet the needs
The practice setting: When providing care, of clients.
nurses consider the setting in which care is given.
Each setting has an impact on the ability to provide Identifying and solving ethical problems requires
ethical care. Quality practice settings create and sensitivity, intellectual curiosity and commitment.
maintain characteristics that support professional If in doubt, nurses need to question and speak with
nursing practice, including appropriate professional colleagues. By discussing and understanding values,
preparation, suitable conditions for nursing practice, and reviewing case situations, nurses can prepare
respect for nurses as responsible decision-makers, themselves for ethical practice.
and recognition of professional expertise.

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Resolving ethical conflicts expectations. These directives only provide

Working through and understanding ethical guidance; nurses need to use judgment at all times
situations is an ongoing part of care. An in-depth in deciding on a course of action.
case study, which begins on page 16, is one example
of a framework for working through ethical Client well-being
situations; other frameworks can also be used. Promoting client well-being means facilitating
the client’s health and welfare, and preventing or
It is not always possible to find a resolution to a removing harm. At times, it is difficult to decide
conflict that satisfies everyone. At these times, the what is “good” or optimal in a particular situation.
best possible outcome is identified in consultation In determining the best action, it is necessary, as
with the client, and the health care team works a beginning point, to differentiate between the
to achieve that outcome. Nurses may still not be nurse’s and the client’s views of what is beneficial.
individually satisfied with the resolution; in this Sometimes it is also difficult to balance potential
case, they need to examine why they’re unsatisfied, benefits with the potential harm of a given
and consider the possibility of taking follow-up treatment choice. Nurses must use the client’s views
action. If a mutually agreeable resolution cannot as a starting point.
be found, it may be necessary to reanalyse the
situation; for example, is there missing data or As in all other types of nursing, nurses who are
misunderstood information? If a resolution still involved in research need to respect clients’ well­
cannot be reached, there will at least be a greater being above all other objectives, including the
understanding. As with other aspects of care, search for knowledge. Research proposals, therefore,
it is necessary to document the discussions and should be prepared according to research standards
decisions. and guidelines for the study of human participants.
Special attention needs to be paid to the issues of
Document layout consent, overuse of clients as participants, the risk-
In each of the following sections, the value is benefit balance, confidentiality of data and the
explained and one or two scenarios, based on real monitoring of research. In collecting data, nurses
situations, are used to assist in understanding how need to watch for adverse responses in participants,
that value can conflict with other values. No answer and to report positive and negative responses
is given because the nature of an ethical dilemma promptly to the research team.
is that there is no one answer. Nurses can use the
scenarios for self-reflection and to generate discussion Scenarios
with their colleagues. Because of the differences in
the value systems among nurses, not all nurses will The following situations illustrate ethical conflicts
find an ethical conflict in every scenario presented. related to client well-being.
However, it is important to understand why the
issue presented may be an ethical problem for other 1. Some of the procedures, such as debridement,
caregivers. The bibliography at the end of this that nurses perform on children may cause the
document includes references containing ethical children to experience severe pain.
conflict scenarios and may be consulted for further
information. 2. Norman, a nurse, has explained to his client the
benefits of taking medication and firmly believes
Each section also specifies behavioural directives; that the medication is in the client’s best interest.
that is, expected behaviours for nurses. The The client understands Norman’s explanation,
directives are not prioritized and are not designed but refuses to take the medication. The client
to work through the scenarios or to provide a states that the side effects of the medication
definitive answer, but rather to describe general cancel out any benefits.

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Behavioural directives decision-maker must always be consulted. In

Nurses demonstrate a regard for client well-being by: Ontario, legislation and common law require that
■listening to, understanding and respecting clients’ the wishes of clients or substitute decision-makers
values, opinions, needs and ethnocultural beliefs; be respected.2
■supporting clients to find the best possible
solution, given clients’ personal values, beliefs and Limits to choice
different decision-making styles; There are limits to client choice. For instance,
■using their knowledge and skill to promote
clients do not have the right to choose to endanger
clients’ best interests in an empathic manner;
the safety of others. Client choice may be restricted
■promoting and preserving the self-esteem and self- by policies that promote health; for example,
confidence of clients; restrictions on smoking. Client choice is also
■maintaining the therapeutic nurse-client
influenced by the resources available in a particular
relationship;
situation.
■seeking assistance when ethical conflicts arise
(for example, from colleagues, ethics committees, There may be situations in which clients request
clergy, literature); nurses to perform an act that is illegal or may cause
■trying to improve the level of health care in the serious harm. In these situations, nurses need to
community by working with individuals, groups, inform clients, in a nonjudgmental manner, about
other health care professionals, employers or the potential risks and harm associated with the
government staff to advocate for needed health practice, or that the practice is illegal in Canada
policy and health resources; or Ontario. By exploring the implications of the
■respecting the informed, voluntary decisions of request and providing education and support to
clients, including participants in research; and clients, nurses have a better chance of preventing a
■minimizing risks and maximizing benefits to practice that has a risk of harm.
clients and research participants (CNA, 1994).
When values differ
Client choice Consideration of clients’ wishes may be difficult
Client choice means self-determination and includes when their beliefs and values differ from those
the right to the information necessary to make of nurses. Nurses have their own personal values
choices and to consent to or refuse care. Clients and may experience an ethical conflict when they
know the context in which they live and their own disagree with clients’ decisions. Nurses may believe
beliefs and values. As a result, when they have the that, as health care professionals, they know what
necessary information, they can decide what is best is best for clients; however, clients have the right to
for themselves. choose a risky course of action.

Clients who are not competent in all areas of When a client’s wish conflicts with a nurse’s
their lives may still be capable of making sound personal values, and the nurse believes that she/he
decisions in some areas and need to be allowed an cannot provide care, the nurse needs to arrange for
opportunity to make decisions in those areas. When another caregiver and withdraw from the situation.
a client is incompetent, nurses need to ensure that If no other caregiver can be arranged, the nurse
a therapeutic relationship is maintained within must provide the immediate care required. If no
the limits possible for the client and with the other solution can be found, the nurse may have to
substitute decision-maker. When individual clients leave a particular place of employment to adhere to
are incompetent to make decisions, a substitute her/his personal values.

2
Other CNO documents, for example, the Consent practice guideline, discuss the consent legislation in greater detail.

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Scenarios
Privacy and confidentiality
Privacy is limited access to a person, the person’s
The following situations illustrate ethical conflicts body, conversations, bodily functions or objects
related to client choice. immediately associated with the person. Because
people have different beliefs and values about
1. A competent 85-year-old man in a long-term privacy, the important aspects of privacy need to
care facility has been taking walks along a busy be identified by individual clients. Nurses need to
highway every day. He always says that he could provide care that maintains the dignity and privacy
not bear to live without his walks. Recently, the of clients and should not unnecessarily intrude on a
nurses have noticed that his gait has become client’s privacy.
unsteady, and they are concerned about his safety
during his walks along the busy road. They are Confidentiality involves keeping personal
afraid that he may fall into the traffic. information private. All information relating to the
physical, psychological and social health of clients is
2. Morry is having increasing difficulty swallowing. confidential, as is any information collected during
Meira, his nurse, has suggested a puréed diet. the course of providing nursing services. Clients,
Morry tries it and finds it intolerable. He decides however, may consent to sharing information with
that he would rather risk choking on more others.
solid food than having to eat what he considers
“baby food.” He requires assistance with feeding Clients have the right to confidentiality, and
himself. Meira wants to support Morry in his nurses make an implicit promise to maintain
choice of eating solids, but is concerned that she confidentiality. Relevant information is shared with
will cause harm by feeding him solids. other members of the health care team, who are also
obliged to maintain confidentiality. Nurses need to
Behavioural directives explain to clients that information will be shared
Nurses demonstrate regard for client choice by: with others on the health care team.
■respecting clients even when the clients’ wishes
are not the same as theirs; At times, nurses learn information which, if not
■following clients’ wishes within the obligations of revealed, will result in serious harm to the client or
the law and the standards of practice; others. Nurses need to consult with the health care
following substitute decision-makers’ directives if
■
team and, if appropriate, report the information
clients are incompetent to make decisions about to the person or facility affected. The client or
their care, within the obligations of the law and substitute decision-maker should be told of the need
standards of practice; to report the information and given the opportunity
■exploring clients’ rationales for their decisions to take action. Some legislation also requires that
before acceding to wishes that the nurse disagrees nurses reveal confidential information to others. For
with. (Can other options be found that coincide example, the Child, Youth and Family Services Act,
with client wishes and the nurse’s knowledge and 2017 requires all health care professionals to report
judgment?); suspected child abuse.
■supporting informed decision-making;
■advocating for clients to acquire information Scenarios
before consenting to, or refusing, care, treatment
or to be a research participant; and The following situations illustrate ethical conflicts
■
making a reasonable effort to identify a substitute related to privacy and confidentiality.
decision-maker if a client is not competent to
make choices regarding health care. 1. The plant manager, who is the occupational
health nurse’s supervisor, has asked to see a
worker’s health record. The nurse refuses to

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release the health record to the manager. The Respect for life
manager becomes angry and says she will Respect for life means that human life is precious
discipline the nurse for not taking direction from and needs to be respected, protected and treated
a supervisor. with consideration (Keyserlingk, 1979). Respect
for life also includes considerations of the quality
2. Jack is HIV-positive and has not told his wife, of life. It is sometimes difficult to identify what
Aimee. Lori, his nurse, asks him to talk with is human life and what society wants, values and
Aimee about his health status since Aimee, as protects in relation to human life. It is also difficult
well as their unborn child, could be at risk. Jack for health care professionals, including nurses, to be
remains adamant that he will not tell Aimee and clear about their own beliefs in relation to human
tells Lori that if she does, he will sue her. life, although it is important that they be aware of
their personal beliefs.
3. Giselle, age six, is in Grade 1. Some parents
overheard a conversation and have decided that Health care professionals need to make every
Giselle has hepatitis. They organize the other reasonable effort to preserve human life.
parents, and soon a delegation meets with the Technology now allows life to be preserved longer.
principal, insisting that they be told the truth. Many health care professionals and clients believe
The principal arranges for the public health nurse that some treatments that preserve life at all
to speak to the parent delegation. The parents tell costs are unacceptable when the quality of life is
Linda, the public health nurse, that they need to questionable.
know the facts about Giselle’s health to protect
their children. When a client’s wish conflicts with a nurse’s personal
values, and the nurse believes that she/he cannot
Behavioural directives provide care, the nurse needs to arrange for another
Nurses demonstrate regard for privacy and caregiver and withdraw from the situation. If no
confidentiality by: other caregiver can be arranged, the nurse must
■ keeping all personal and health information provide the immediate care required. In the longer
confidential within the obligations of the law term, the nurse may have to leave a particular place
and standards of practice, including that which is of employment to adhere to her/his personal values.
documented or stored electronically. (For further
information, see the Documentation, Revised 2008 Scenario
practice standard);
■ informing clients or substitute decision-makers The following situation illustrates an ethical
that other health care team members will have conflict related to respect for life.
access to any information obtained while caring
for clients; Tina has stated that she never wants to be
■ informing clients or substitute decision-makers dependent on technology to live. She has MS and
who comprise the health care team; was recently admitted to a long-term care facility.
■ informing clients or substitute decision-makers On admission, she stated that she never wants a
that information may be used for purposes feeding tube or to have CPR. Last week, she had
other than client care (e.g., research, quality a stroke and is uncommunicative. The health care
improvements); team is considering approaching her husband to
■ refraining from collecting information that is obtain consent for a feeding tube. Misha, her nurse,
unnecessary for the provision of health care; and is distressed that the team is considering such an
■ protecting clients’ physical and emotional privacy. intervention.

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Behavioural directives members. The nurse is being pressured by other

Nurses demonstrate regard for respect for life by: members of the health care team to talk the family
■identifying, when possible, clients’ values about into taking the client home.
respect for life and quality of life;
■respecting clients’ values and following their
Behavioural directives
wishes within the obligations of the law and
Nurses demonstrate a regard for maintaining
standards of practice;
commitments to clients by:
■following substitute decision-makers’ directives if ■ putting the needs and wishes of clients first;
clients are incompetent to make decisions about ■ identifying when a client’s needs and wishes
their care, within the obligations of the law and conflict with those of the family or others and
standards of practice; encouraging further discussion about client needs;
advocating for palliative measures when active
■ ■ identifying needed resources and support to
treatment is withheld; and enable clients to follow their wishes;
■providing dignified, comfortable care for a dying ■ identifying when their own values and beliefs
client. conflict with the ability to keep implicit and
explicit promises and taking appropriate action;
Maintaining commitments ■ providing knowledgeable and client-centred
Nurses have an obligation to maintain the nursing care;
commitments they assumed as regulated health ■ advocating for maintaining quality client care;
professionals. Maintaining commitments means and
keeping promises, being honest and meeting ■ making all reasonable efforts to ensure that client
implicit or explicit obligations toward their clients, safety and well-being is maintained during any
themselves, each other, the nursing profession, job action.
other members of the health care team and quality
practice settings. Maintaining commitments to oneself
As people learn and grow, they develop their
Maintaining commitments to clients personal values and beliefs. Nurses need to
Nurses, as self-regulated professionals, implicitly recognize and function within their value system
promise to provide safe, effective and ethical care. and be true to themselves. Nurses’ values sometimes
Because of their commitment to clients, nurses try differ from those of other health care professionals,
to act in the best interest of clients according to employers and clients, causing ethical conflict.
clients’ wishes and the standards of practice. Nurses Nurses must provide ethical care while at the same
are obliged to refrain from abandoning, abusing time remaining committed to their values.
or neglecting clients, and to provide empathic and
knowledgeable care. The commitment to clients When a client’s wish conflicts with a nurse’s
also includes a commitment to respect family personal values, and the nurse believes that she/he
members and/or significant other(s), some of whose cannot provide care, the nurse needs to arrange for
needs may conflict with those of clients. another caregiver and withdraw from the situation.
If no other caregiver can be arranged, the nurse
Scenario must provide the immediate care required. In the
long term, the nurse may have to leave a particular
The following situation illustrates an ethical place of employment to adhere to her/his personal
conflict related to maintaining commitments to values.
clients.
Scenario
A client wants to die at home in peace and comfort.
The family knows that the presence of the client at The following situation illustrates an ethical conflict
home will create intolerable stress for other family related to maintaining commitments to oneself.

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The family of a client who has been in a coma one another, and refer to each other when they do
for some time has requested that the feeding tube not have the necessary competence to provide a
be withdrawn and that the client be allowed to specific part of the nursing care.
die. One nurse is very upset about the prospect of
caring for a client for whom she is not allowed to However, in situations in which clients’ safety
provide nourishment. She believes that providing and well-being are compromised, nurses’ primary
nourishment is fundamental to caring. responsibility is to their clients. Nurses, therefore,
need to take action when colleagues put clients at
Behavioural directives risk or are abusive toward clients in any way. (For
Nurses demonstrate a regard for maintaining further information, see the Therapeutic Nurse-
commitments to themselves by: Client Relationship, Revised 2006 practice standard
■ clarifying their own values in client situations; and the Professional Misconduct document.)
■ identifying situations in which a conflict of their
own values interferes with the care of clients; Scenario
■ exploring alternative options for treatment and
seeking consultation when values conflict; The following situation illustrates an ethical
■ determining and communicating their values conflict related to maintaining commitments to
pertinent to a position before accepting it; and nursing colleagues.
■ recognizing their physical and mental limitations,
and the impact their own health has on their Candice, an RN, observes Michelle, another RN,
ability to provide safe, effective and ethical care. speaking in a loud, angry manner to Kate, an RPN.
Michelle is criticizing Kate about her nursing care.
Maintaining commitments to nursing Kate’s client is nearby and can hear every word.
colleagues Candice realizes that this kind of behaviour is
Nurses have a commitment to each other. Nursing unprofessional and can have a very negative impact
is one profession with two categories of registration: on Kate’s relationship with her client. The client
Registered Practical Nurses (RPNs) and Registered may start to distrust Kate’s ability to competently
Nurses (RNs), which includes Nurse Practitioners care for him. Candice also recognizes that all the
(NPs). Ethical nurses are concerned about the RNs, herself included, have been upset recently.
well-being of nursing colleagues and therefore are There are rumours that RNs are going to be laid off
respectful toward each other. Respectful behaviour and replaced with RPNs.
among nurses contributes to the best possible
outcomes for clients (Hansen, 1995). Behavioural directives
Nurses demonstrate regard for maintaining
Reorganization and job uncertainty can have a commitments to nursing colleagues by:
negative impact on the way nurses work together ■
showing a caring attitude by expressing warmth,
and relate to each other. More than ever, nurses interest and empathy toward one another;
need to work collaboratively and promote an ■ knowing and respecting each others’ roles, scopes
environment of collegiality. This means that nurses of practice and the collaborative nature of practice
show consideration and respect for each other. between RNs, NPs and RPNs;
Establishing and maintaining collegial relationships ■
contributing to positive team functioning and
requires nurses to use a wide range of commu­ supporting one another;
nication strategies and effective interpersonal skills. ■ introducing themselves to colleagues and
addressing colleagues by the name or title that
Nurses have a duty to know and acknowledge each their colleagues prefer;
colleague’s role and unique contributions to the ■
listening to colleagues without immediately giving
team effort. Nurses trust in the expertise of one advice or diminishing colleagues’ feelings;
another, share their expertise and knowledge with

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■ giving colleagues the time and opportunity to each nurse is accountable for the responsibilities
explain themselves and to ask questions; that accompany this privilege.
■
understanding and respecting colleagues’ values,
opinions and needs; Scenario
■ exploring colleagues’ unusual comments, attitudes
or behaviours to discover the underlying meaning; The following situation illustrates an ethical
■
discussing and working through ethical conflicts conflict related to maintaining commitments to the
and concerns with one another; nursing profession.
■
knowing the expertise of colleagues and accessing
it when clients would benefit from that expertise; Mary has a friend at work, Cory, who is under a
■ sharing nursing knowledge and expertise with
great deal of personal stress. Cory has indicated
others, including nursing students;
that she is grateful for the support and help she
■
learning and practising effective communication is receiving from her nursing colleagues. Mary,
with colleagues; however, has begun to notice that Cory’s practice
■ providing peer feedback in a respectful manner; has become much less competent. Cory is failing
■ recognizing that substance abuse by to do appropriate assessments of her clients. Mary
colleagues is a health problem requiring prompt has also noted that, at times, Cory’s judgment
assistance, support and treatment; has seemed impaired and that she is increasingly
■
intervening in situations in which the safety and disorganized. Cory is also becoming short-tempered
well-being of clients are compromised; and with other staff and abrupt to clients. No serious
■ reporting to the appropriate authority any nursing mistakes have been made as of yet. Mary has tried
colleague whose actions or behaviours toward to speak to Cory about her concerns, but Cory says
clients are unsafe or unprofessional, including she’s doing fine. Mary realizes that action needs to
any physical, verbal, emotional, financial and/or be taken, although she does not wish to add to her
sexual abuse. friend’s problems by reporting Cory to the nurse
manager.
Maintaining commitments to the nursing
profession Behavioural directives
Nurses have a commitment to the nursing Nurses demonstrate regard for maintaining
profession. Being a member of the profession brings commitments to the nursing profession by:
with it the respect and trust of the public. To ■ promoting the goals of the profession in a manner
continue to deserve this respect, nurses have a duty that meets the needs of clients;
to uphold the standards of the profession, conduct ■
conducting themselves in a way that promotes
themselves in a manner that reflects well on the respect for the profession;
profession, and to participate in and promote the ■ participating in CNO’s Quality Assurance

growth of the profession. (For further information, Program;

see CNO’s Professional Standards, Revised 2002 ■

contributing to continual quality improvement
practice standard.) initiatives for the profession;
■
following the standards and practice expectations
As members of a self-regulating profession, nurses of the profession;
also have a commitment to help regulate nursing to ■ notifying CNO of issues that are relevant for safe,
protect the public’s right to quality nursing services. effective and ethical care;
It is in the public’s interest that the profession ■
assisting CNO in developing standards, practice
continue to regulate itself by developing and expectations and position statements;
changing the methods of self-regulation to meet the ■ cooperating with regulatory functions (e.g., an
changes in health care and society. Nurses have an investigation of a peer’s practice); and
obligation to participate in the effective evolution ■ being accountable for their actions and

of self-regulation. Self-regulation is a privilege, and behaviours.

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Maintaining commitments to team ■ knowing and respecting each team member’s role
members/colleagues and scope of practice;
Much of what has been expressed in the above ■
conducting themselves in a way that promotes

paragraphs about commitment to nursing colleagues respect for team members;

applies equally to other members of the health ■ contributing to positive team functioning and

care team. Nurses need to respect all health care supporting one another;

professionals and their roles, and are expected to ■

exploring colleagues’ unusual comments, attitudes
collaborate and coordinate care with team members. or behaviours to discover the underlying meaning;
When there are overlapping scopes of practice ■
showing a genuine interest in colleagues and

between professions, the nurse needs to determine being empathetic;

the appropriate care provider and what is in the ■ discussing and working through ethical conflicts
client’s best interest. and concerns with team members;
■
knowing the expertise of team colleagues and
Establishing and maintaining collegial relationships accessing it when clients would benefit from that
requires nurses to use a wide range of effective expertise;
communication strategies and interpersonal skills. ■ sharing nursing knowledge and expertise with
Team cohesiveness is necessary to promote the team members;
best possible outcomes for clients. In situations in ■
learning and practising effective communication
which client safety and well-being are compromised, with colleagues;
however, nurses’ primary responsibility is to their ■
providing peer feedback in a respectful manner;
clients. Nurses, therefore, take action when team ■ recognizing that substance abuse by colleagues
members put clients at risk or are abusive of clients is a health problem requiring prompt assistance,
in any way. (For further information, see CNO’s support and treatment;
Therapeutic Nurse-Client Relationship, Revised 2006 ■
intervening in situations in which the safety and
practice standard and its Professional Misconduct well-being of clients is compromised; and
document.) ■ reporting to the appropriate authority any team
member or colleague whose actions or behaviours
Scenario toward clients are unsafe or unprofessional,
including any physical, verbal, emotional,
The following situation illustrates an ethical financial and/or sexual abuse.
conflict related to maintaining commitments to
health care team members. Maintaining commitments to quality
practice settings
Sarah knows that the wrong medication was Nurses are best able to provide quality care when
prescribed and administered to a client. There was their environment supports quality professional
no bad effect on the client, and the appropriate nursing practice, is effective in implementing
treatment has been resumed. The physician change and responds to nurses’ concerns. All nurses,
and nurse involved in the incident are excellent whatever their position, need to advocate for quality
practitioners and are very upset by the error. No one practice settings. To promote quality workplaces,
has informed the client of this mistake, believing CNO has identified key attributes or characteristics
that informing may have professional implications that support quality professional practice. These
for the nurse and physician and may erode the are: professional development systems, leadership,
client’s trust in the health care team. organizational supports, response systems facilities
and equipment, communication systems and care
Behavioural directives delivery processes. Nurses should refer to these
Nurses demonstrate regard for maintaining attributes when advocating for improvements to
commitments to health care team members/ their practice settings.
colleagues by:

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Scenario
■ determining and communicating values to staff;
■
being informed about the scopes of practice of all
The following situations illustrate ethical conflicts health care team members;
related to maintaining commitments to quality ■ providing clear role expectations for nurses
practice settings. (Freiburger, 1996);
■ assigning responsibilities to staff according to
1. A number of nurses have been very unhappy with their scope of practice and individual abilities;
the level of staffing in their facility. They believe ■
providing, and/or advocating for, needed
that clients are receiving unsafe care. They have resources for safe, effective and ethical nursing
spoken with management about their concerns care;
and were told that the implemented changes ■ promoting positive collegial relationships;
are in the best interest of client care. Someone ■ showing sincere appreciation for staff

has suggested they talk to their MPP about the contributions (Hansen, 1995); and

care. Others feel that they first need to pursue ■

looking into and following up on concerns

their concerns within the organization. They are of staff.

concerned that talking to their MPP might harm

the reputation of the facility. Truthfulness
Truthfulness means speaking or acting without
2. Morgan, a nurse with 10 years of experience intending to deceive. Truthfulness also refers to
in the organization, is seen by her nursing providing enough information to ensure the client
colleagues as a leader. They approach her to lead is informed. Omissions are as untruthful as false
a delegation to speak to the senior administrator information. As health care has changed, so have
about their concerns regarding equipment and the restrictions on disclosure in dealing with clients.
cleanliness in the workplace. Two days earlier, Many health care professionals formerly believed
Morgan was informed that she was being that clients could be harmed by knowing the details
considered for a promotion to a management of their illnesses. Health care professionals now
position. believe that clients have the right to and will benefit
from full disclosure. Honesty builds trust, which
Behavioural directives is essential to the therapeutic relationship between
Nurses demonstrate regard for maintaining nurses and clients.
commitments to quality practice settings by:
■
continually evaluating the workplace environment Clients from other cultures, however, may view
to identify opportunities for improving the truthfulness differently from the health care team.
quality of care; Situations may arise in which full disclosure is
■ respecting the philosophy and policies of the
difficult and conflicts develop among team members.
practice setting;
Conflicts may also occur among the team, the family
■
making those in authority aware of concerns and the client, as each group or person brings a
within the setting; particular set of values to the situation.
■ exploring solutions within the setting that will
meet the needs of clients and those of the setting; Scenario
■ advocating for nursing input into policies relating
to client care; and The following situations illustrate ethical conflicts
■
determining and communicating personal values related to truthfulness.
they may bring to a position before accepting
employment. 1. David does not want his father, the client, to
know the seriousness of his condition. The father,
Nurse leaders also demonstrate their commitment however, is asking the nurse questions and wants
to quality practice settings by: to know more.

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2. Sam’s client has indicated that he does not wish the decisions in a particular situation. In some
to hear the truth about his illness. Sam is obliged situations, no decision will adequately address all
to be truthful, and his client has the right to the concerns.
decide about the care he receives.
When nurses find that resources are too scarce to
Behavioural directives provide care that meets the standards of practice,
Nurses demonstrate a regard for truthfulness by: they need to promptly make their concerns known.
■
discussing clients’ direct questions about
Nurses need to provide the best possible care under
their diagnosis with the health care team and
the circumstances.
advocating for the clients’ right to receive the

information;
Scenario
■assessing the clients’ readiness for information;
■answering the clients’ direct questions if nurses The following situation illustrates an ethical
have the information, or seeking the answer for conflict related to fairness.
clients;
■using professional judgment and consulting with Sharon, a public health nurse, has just learned that
the health care team if further information is the budget for safer sex and smoking-cessation
relevant to clients, but is not asked for because programs has been cut. Also, funding for a program
clients do not know the information exists; to assist high-risk mothers and babies has also been
■
explaining to clients their right to information; drastically reduced. Research has shown that these
■assisting clients in understanding information
programs are effective and cost-efficient.
when there are cultural, language or literacy

concerns;
Behavioural directives
■
assessing the whole situation when clients indicate Nurses demonstrate regard for fairness by:
that they do not want to know something; and ■being clear about how their own values relate to
■giving consideration to families’ and/or significant the demands of fairness;
other(s)’ points of view when they do not want ■discussing resource allocation issues with the
clients to be told about their health condition. appropriate authority and the health care team so
that all can be involved in resolving a problem;
Fairness ■advocating for input into policies and procedures
Fairness means allocating health care resources on about the use of resources;
the basis of objective health-related factors. The ■
advocating for adequate resources to provide safe,
Canada Health Act provides access to health care for effective and ethical nursing care;
all Canadians. Health care resources, however, are ■working with other health care professionals to
limited; this makes it difficult to make decisions advocate for social changes that promote quality
about who receives care and what kind of care they practice settings and client well-being; and
receive. ■demonstrating a willingness to explore alternative
ways of providing care that continue to value
Decisions for entitlement to care can be made in clients’ well-being.
a number of ways. Nurses could consider that all
clients should have equal attention, regardless of Working Through Ethical Situations
needs. Nurses might also prioritize an individual in Nursing Practice
client’s needs according to the critical nature of that Because of the nature of ethics, it is sometimes
need. Nurses could also look at who will benefit difficult to identify precisely the issues causing
most from the care they can give. How decisions the ethical situation. Complex, moral and value-
are made will depend on the context and the laden situations are not easily understood and dealt
nurse’s specific role in the situation. Nurses need to with. Working through ethical situations begins
be aware of the rationale they have used to make with understanding the values of all concerned.

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Because nearly every ethical situation involves other to concentrate more fully on nursing care, helping
members of the health care team, these people need to alleviate the problem.
to be part of the discussion to resolve the issues
and develop an acceptable plan of care. An ethics Plan/approach
resource person in the agency, such as an ethicist, ■ Develop an action plan that takes into account
clergy member or ethics committee, can also be factors drawn from the assessment, options and
of assistance. Other resources are literature, CNO consequences. Sometimes doing nothing is the
Practice Consultants and the Joint Centre for best course of action. This should be a conscious
Bioethics at the University of Toronto. decision, since doing nothing will affect the
outcome and should not be a means of avoiding a
There are many ways of working through and decision.
understanding ethical situations. One example of ■ Decide which is the best course of action.
how to do this is included in this section. For other Sometimes a completely good outcome is
examples, refer to the bibliography, which begins on impossible; the best possible outcome may be the
page 19. one that is least bad. (In a case of staff shortages,
it may be that reorganizing the work allows nurses
Due to its familiarity to nurses, the nursing to give safe care, although the nurses may still
process provides a viable approach for examining believe that the quality of care is reduced.)
situations involving ethical values. These situations ■
Consult with anyone who disagrees and consider
may involve ethical uncertainty, ethical distress or her/his position. Perhaps a further assessment
ethical conflicts. of the situation needs to take place, and the
dissenting person needs to be involved in the
Assessment/description of situation planning. If a person is involved in the decision-
■
Pay close attention to all aspects of the situation, making process but disagrees with the final plan,
taking into account clients’ beliefs, values, wishes she/he has an obligation to respect the decision
and ethnocultural backgrounds. made. If she/he cannot accept the decision,
■Examine not only your beliefs, values and she/he needs to arrange for another caregiver
knowledge (see Maintaining Commitments to and withdraw from the situation. (For more
Oneself on page 9), but also those of others on the information, see Maintaining Commitments to
health care team. Oneself on page 9.)
Consider policies and guidelines, professional
■

codes of ethics and relevant legislation. Implementation/action

■Hold a discussion with all involved to clarify the ■ Carry out the agreed upon actions. Sensitivity,
process. When thoughtful consideration has been good communication and interpersonal skills are
given to all of these factors, the necessary. All who are affected by the situation
nature of the concern is clarified and the need to be kept informed.
issues are identified. ■ Provide information and emotional support for
■Clearly state the ethical concern, issue, problem or the client, the family, friends and caregivers;
dilemma. implementation may be very stressful.
Identify a broad range of options and their
■

consequences. Options that at first may not Evaluation/outcome

seem feasible need to be considered as a way of ■
Determine if the result is satisfactory.
strengthening analysis and decision-making. ■ Involve those who were part of the initial
For example, staff may believe that client care is assessment and planning, including the client.
compromised. One option is to look at staffing ■ Reassess and re-plan if others are concerned
and hire more staff, but fiscal restraints make it with the outcome. For example, a client refuses
impossible. Looking at staffing, however, may a recommended treatment. The team has done
lead to reorganizing the workload to allow nurses everything possible to inform the client of the

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consequences of refusing the treatment. Further respect confidentiality. Confidential information

assessment might uncover ethnocultural beliefs can be disclosed when a person(s) is at serious
that make it impossible for the client to agree to risk. However, it is preferable if the client discloses
the treatment. In light of this information, the the information. If the client refuses, the nurse is
team can either recommend another treatment or obligated to take action to prevent serious harm to
accept the client’s decision. an innocent person(s).
■ Consider policies and guidelines for subsequent
situations and decisions, and revise them as Joanne decides that she needs to know more about
necessary. John’s clinical situation and sees John’s psychiatrist
■ Assess the time allowed for ethical decision- the next time she is working. The psychiatrist is
making. Many ethical dilemmas occur when surprised that John has this type of employment
there is not enough time to consider the issues as he was discharged on the condition that he
properly. have only supervised contact with children. The
psychiatrist shares Joanne’s concerns.
Evaluation will help sensitize participants to ethical
thinking and improve their ability to work through With the information she has, Joanne thinks
ethical dilemmas. the dilemma is whether she should break client
confidentiality to protect children from the threat
Scenario of serious harm. Joanne is also concerned about
John’s well-being, now that he is living in the
The following situation illustrates an ethical community and has found employment. As well,
dilemma and has been worked through using by disclosing confidential information, she will not
the proposed framework. This scenario provides have maintained a commitment to a client.
an answer for the purpose of understanding the
framework. A similar real-life situation would Joanne has several options
need to be worked through in the context of the 1. Do nothing. She would not tell John’s new
particulars of that situation before choosing the employer or her neighbours, reasoning that she
third option. is uncertain about the risk and wants to err on
the side of caution by not disclosing confidential
One of Joanne’s clients in the psychiatric unit, information. She will, however, tell her children
John, confides to her that he is fascinated by young to avoid him.
children, boys and girls. He tells Joanne he is
afraid that he will hurt a child some day. Joanne In choosing this option, Joanne is potentially
brings that information to the team. A short time placing children at risk and is, therefore, not
later, John is discharged. Some weeks following his following her professional obligations to prevent
discharge, Joanne notices that John is the ice-cream potential serious harm. Joanne is overlooking the
vendor in her neighbourhood. She is concerned for fact that to do nothing is a decision to be passive
the children in the neighbourhood, her own as well (i.e., an act of omission is an act of commission).
as the others, and wonders what she should do. She has failed to honour her commitment to her
client and others.
A. Assessment/description of situation
Joanne decides that she needs more information. 2. Reveal confidential information. Joanne
She reviews her professional obligations by referring would tell John’s employer of the potential
to CNO’s Ethics and Professional Standards, risk, considering that she must protect the
Revised 2002 practice standards. Joanne then neighbourhood children from potential harm.
consults a colleague, who teaches ethics to nursing
students, and a Practice Consultant at CNO. Both With this option, Joanne might protect the
individuals tell her that there is no absolute duty to children from potential risk, but at a great cost.

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PR ACTICE STANDARD

The result of revealing this information would be provide appropriate care and maintain a commit­
that John would probably lose his job, come to ment to the client and others.
mistrust nurses and deteriorate clinically. Again,
Joanne would not have honoured her professional C. Implementation/action
obligation to protect client confidentiality. Joanne contacts John, and he agrees to see the
psychiatrist. John is assessed and found to present a
3. Try to meet both her obligation to protect the danger. John agrees to treatment and is admitted to
public and to protect her client’s confidentiality the psychiatric facility.
and well-being. Working with the mental
health care team, Joanne would arrange for Another finding could have been that John does not
John to be assessed by the team to determine pose a risk to children and, therefore, there is no
whether he poses a danger to children at this justification for disclosing confidential information
time. If the team determines that John poses a to anyone.
serious danger to children, it must then decide
how to respond to this situation. John could D. Evaluation/outcome
be an involuntary client unless he agreed to be The team meets to assess how John “slipped
admitted to a psychiatric facility. If it were found through the cracks.” The team determines that
that John does not pose a danger, then there is no heavy workloads brought on by staff cutbacks have
justification to disclose confidential information. resulted in some clients being discharged too early.
The discharge planning process for clients who have
With this option, Joanne can begin to meet her a history of dangerous behaviour is re-evaluated to
obligations to the client and to the public. prevent another premature discharge. As well, the
team proposes a follow-up program for clients with
B. Plan/approach similar mental health problems. Joanne is praised
Joanne chooses the third option. The team decides for her swift attention to a potentially dangerous
to ask John if he will agree to see his psychiatrist situation. An educational program regarding the
for an assessment. Joanne is chosen to contact John criteria for involuntary admission and respect for
because she is the team member who has had the confidentiality is arranged.
closest therapeutic relationship with him.
At the end, Joanne reflected and realized that if
Her justification for this option is that the priority she had taken the second option and revealed the
is to respect client well-being. John may need client’s confidential information, John would not
further care and, if so, this should be provided. have received needed care. Also, he could have
Joanne’s other priority is to prevent harm to others. moved and presented a danger to children in a
To do so, she realizes that she has to determine different location. She also realized that the first
whether John is a serious risk to children. By option to do nothing would have been less trouble
thinking through the problem, Joanne realizes in the short run, but could have led to serious and
that whether to disclose confidential information harmful consequences for John and the children
is not the ethical dilemma. When she reflects on later on.
the situation, Joanne sees that giving confidential
information to an employer and the neighbourhood
would not protect children because John could
move to another town. The real issue is how to

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Conclusion
This ethical framework is designed to provide
nurses with direction in identifying and resolving
ethical situations. Because nurses will not be
able to address every situation that arises alone,
they will need to access resources and use their
judgment based on the particulars of the situation.
Continuing education about ethical issues and
conflicts will help nurses and other health care
professionals understand and resolve new ethical
situations. Reading and discussing this document
is a first step in the process. Ongoing self-reflection
and further discussion with peers about these issues
will contribute to nurses’ ability to resolve ethical
situations in their practice. A selected bibliography
has been included to assist in further education
about ethics.

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Selected Bibliography Gadow, S. (1980). A model for ethical decision-

This bibliography is intended to provide nurses with making. Oncology Nursing Forum, 7(4),
sources for further reading about the therapeutic pp. 44–47.
relationship and related ethical values. Its purpose
is to assist RPNs and RNs in their continuing Grant, A. (1992). Exploring an ethical dilemma.
education. This is not a comprehensive bibliography Nursing 92, 22(12), pp. 52–54.
for academic research. Entries have been chosen
from journals and books that are readily available to Hansen, H. (1995). A model for collegiality among
most RPNs and RNs. staff nurses in acute care. Journal of Nursing
Administration, 25(12), pp. 11–20.
Journals
Brody, J. (1988). Virtue, ethics, caring and nursing. Heinrich, K. (1992). What to do when a patient
Scholarly Inquiry for Nursing Practice: An
becomes too special. Nursing 92, 22(11),
International Journal, 2(2), pp. 87–95.
pp. 63–64.

Clark, L., Robbs, L. & Walkerley, S. (1993). Krouse H. & Roberts, S.J. (1980). Nurse-patient
Potential and pitfalls of a nursing ethics interactive styles: power, control, and satisfaction.
subcommittee. Registered Nurse, 5(3), Western Journal of Nursing Research, 11(6), pp.
pp. 9–11. 717–725.

Comack, M. (1993). Feeding the dying: Myths & Lund, M. (1991). Stopping treatment: Who decides?
realities. Registered Nurse, 5(3), pp. 20–21. Geriatric Nursing, 12(3), pp. 147–151.

Curtin, L. (1994). Collegial ethics of a caring Marck, P. (1990). Therapeutic reciprocity: A caring
profession. Nursing Management, 25(8), phenomenon. Advances in Nursing Science, 13(1),
pp. 28–32. pp. 49–59.

Curtin, L. (1993). Creating moral space for nurses. Milner, S. (1993). An ethical nursing practice
Nursing Management, 24(3), model. Journal of Nursing Administration, 23(3),
pp. 18–19. pp. 22–25.

Ericksen, J. (1993). Putting ethics into education. Moorhouse, A., Caulfield, P., Donner, G. &
The Canadian Nurse, 89(5), pp. 18–20. Thomas, J. (1993). A pilot study of bioethics
education of nursing students. Registered Nurse,
Ericksen, J. (1989). Steps to ethical reasoning. The 5(3), pp. 16–19.
Canadian Nurse, 85(7), pp. 23–24.
Morse, J., Solberg, S., Neander, W., Bottorff, J. &
Foster, P., Larson, D. & Loveless, E.M. (1993). Johnson, J. (1990). Concepts of caring and caring
Helping students learn to make ethical decisions. as a concept. Advances in Nursing Science, 13(1),
Holistic Nursing Practice, 7(3), pp. 1–14.
pp. 28–35.
Moulsdale, W. & Johnston-Canjar, S. (1993). A
Fowler, M. (1989). Ethical decision-making in nurse’s view: Ethics in the neonatal intensive care
clinical practice. Nursing Clinics of North America, unit. Registered Nurse, 5(3), pp. 14–15.
24(4), pp. 955–965.
Nelson, H. (1992). Against caring. The Journal of
Fry, S. (1989). Toward a theory of nursing ethics. Clinical Ethics, 3(1), pp. 8–15.
Advances in Nursing Science, 11(4), pp. 9–22.

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PR ACTICE STANDARD

Noddings, N. (1992). In defence of caring. The

Journal of Clinical Ethics, 3(1), pp. 15–18.

Nyberg, J. (1989). The element of caring in nursing

administration. Nursing Administration Quarterly,
13(3), pp. 9–16.

Omery, A. (1989). Values, moral reasoning, and

ethics. Nursing Clinics of North America, 24(2),
pp. 499–508.

Roberts, J. (1990). Uncovering hidden caring.

Nursing outlook, 38(2), pp. 67–69.

Rodney, P. (1989). Towards ethical decision-making

in nursing practice. Canadian Journal of Nursing
Administration, 2(2), pp. 11–14.

Salsberry, P. (1992). Caring, virtue theory, and a

foundation for nursing ethics. Scholarly Inquiry
for Nursing Practice, 6(2),
pp. 155–167.

Tunna, K. & Conner, M. (1993). You are your

ethics. The Canadian Nurse, 89(5), pp. 25-26.

Vezeau, T. (1992). Caring: From philosophical

concerns to practice. The Journal of Clinical
Ethics, 3(1), pp. 18–20.

Wagner, M. (1991). A question of informed consent.

Nursing 91, 21(4), pp. 66,68.

Wagner, M. (1993). To tell or not to tell. Nursing

93, 23(3), pp. 50–53.

Walker, M. (1993). Keeping moral space open:

New image of ethics consulting. Hastings Center
Report, 23(2), pp. 33–40.

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Books Kluge, E. (Ed). (1993). Readings in bioethical ethics:

Baylis, F. & Downie, J. (Eds). (1992). Codes of A Canadian focus. Scarborough, ON: Prentice
ethics: Ethics codes, standards, and guidelines for Hall.
professionals working in a health care setting in
Canada. Toronto: Department of Bioethics, The Monagle, J. & Thomasma, D. (1993). Medical
Hospital for Sick Children. ethics: Policies, protocols, guidelines and programs.
Gaithersburg, MD: Aspen.
Beauchamp, T. & Childress, J. (1989). Principles
of biomedical ethics. (3rd ed). New York: Oxford Pence, T. & Cantrall, J. (1990). Ethics in nursing:
University Press. An anthology. New York: National League for
Nursing.
Bishop, H. & Scudder, J. (Eds). (1985). Caring,
curing, coping: Nurse, physician, patient Registered Nurses Association of British Columbia.
relationships. Birmingham, AL: University of (1998). Standards for nursing practice in British
Alabama Press. Columbia. Vancouver, BC: Author.

Canadian Nurses Association. (1997). Code of ethics Roy, D., Williams, J. & Dickens, B. (1994).
for registered nurses. Ottawa, ON: Author. Bioethics in Canada. Scarborough, ON: Prentice
Hall.
Canadian Nurses Association. (1994). Ethical
guidelines for nurses in research involving human Victorian Order of Nurses, Hamilton-Wentworth
participants. Ottawa, ON: Author. Branch. (1993). Ethics in the community: A
learning package for health care professionals.
Canadian Nurses Association. (1997). Everyday Hamilton, ON: Author.
ethics... putting the code into practice. Ottawa, ON:
Author. Yeo, M. (1996). Concepts and cases in nursing ethics.
(2nd ed). Peterborough, ON: Broadview Press.
Curtin, L. & Flaherty, M. (1982). Nursing Ethics:
Theories and pragmatics. Bowie, MD: Robert J.
Brady

Fry, T. (1994). Ethics in nursing practice: A guide

to ethical decision-making. Geneva, Switzerland:
International Council of Nurses (ICN).

Holmes, H. & Purdy, L. (Eds). (1992). Feminist

perspectives in medical ethics. Bloomington and
Indianapolis: Indiana University Press.

Jameton, A. (1984). Nursing practice: The ethical

issues. Englewood Cliffs, NJ: Prentice Hall.

Keyserlingk, E. (1979). Sanctity of life or quality

of life. (Protection of Life Series Study Paper).
Ottawa, ON: Law Reform Commission of
Canada.

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Notes:

College of Nurses of Ontario Practice Standard: Ethics

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PR ACTICE STANDARD

Notes:

College of Nurses of Ontario Practice Standard: Ethics

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