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Study guide · Safe and Effective Care Environment

Management of Care

18 to 24% of the exam · 29 activity statements

Management of Care is the largest area of the REx-PN: how the practical nurse in British Columbia and Ontario provides and directs care that is safe, legal, ethical and organized. Items ask whom to see first, what to assign to a UCP, when to consult the RN or primary health care provider, and how to handle orders, consent, privacy, advance directives, mandatory reports and culturally safe care. Most items are judgment decisions, not recall.

A study feature written by ExamDragon, not part of the real exam. Each heading is one of the Related Activity Statements the Test Plan lists for this category (29 of them), in our words; the official wording is in the Test Plan.

At a glance

Safe and Effective Care Environment
18 to 24%

of the exam (the Test Plan's range)

Activity statements
29
Key terms
15

What this guide covers, statement by statement

  1. Keep client information private and confidential
  2. Stay within the scope of practice the law sets for you
  3. Draw on evidence, technology and policies to improve care
  4. Speak up for what clients need and are entitled to
  5. Give and take report on the clients you are assigned
  6. Start, review and revise the client's care plan
  7. Notice ethical dilemmas and respond to them properly
  8. Act in line with the nursing code of ethics, fairly and without causing harm
  9. Decide the order in which clients get care
  10. Plan your workload so time is used well
  11. Assign care to others, such as unregulated care providers, and oversee it
  12. Judge when a referral or consult is needed and get the orders for it
  13. Take and transcribe orders from prescribers
  14. Obtain the client's consent before care or a procedure and explain what it involves
  15. Build the client's advance directives into the care plan
  16. Work with other disciplines on the client's care
  17. Take part in resolving disagreements
  18. Know the limits of your own skills and ask for help
  19. Make legally required reports, such as suspected abuse or reportable disease
  20. Carry out admissions, transfers and discharges safely
  21. Teach clients and staff what clients' rights and responsibilities are
  22. Take part in quality and performance improvement work
  23. Document care using accepted terms and abbreviations
  24. Step in and report when another provider's practice is unsafe
  25. Include the client in decisions about their care
  26. Review and build your own competence through reflection and learning
  27. Support and teach new staff and students
  28. Draw on Indigenous ways of knowing and healing when caring for Indigenous clients
  29. Give fair care with equal access for every client, whatever their sexual orientation or gender identity or expression

1Keep client information private and confidential

  • Share health information only with people in the client's circle of care who need it for that client's care, or with the client's express consent.
  • Verify identity and authority before giving information by phone or in person; when in doubt, ask the client and follow the agency's policy (for example, a password the client chose).
  • Look up only the records of clients you care for; opening any other record, including a coworker's or a relative's, is a privacy breach even if nothing is shared.
  • Protect information in every form: log off or lock screens, keep paper out of sight, never post about clients or the workplace on social media, and talk about clients only in private places.
  • Report a privacy breach (yours or someone else's) promptly to the manager or privacy officer as agency policy and privacy legislation require.
  1. In practiceA man phones the surgical unit saying he is a client's brother and asks how her surgery went. The nurse does not confirm that the client is on the unit, offers to take his number and asks the client whether she wants information shared with him, because consent and identity have not been established.
  2. Where questions turnGiving information to a caller or visitor because they sound credible or say they are family, instead of checking consent and identity first.
Practise this activity

2Stay within the scope of practice the law sets for you

  • Scope of practice is set by provincial legislation and the regulator's standards; your own scope is narrower still, limited by your competence and your employer's policies.
  • Practical nurses care independently for clients whose outcomes are predictable; as complexity, instability or risk rises, consult and collaborate with the RN, and transfer care when the client's needs exceed your role.
  • Before you perform any activity, ask three questions: does legislation and my regulator allow it, does employer policy allow it, and am I competent to do it safely?
  • An order from a primary health care provider does not make an activity safe or within your scope; if it is not, decline it and tell the provider and the RN or manager.
  • Accountability is personal: you answer for your own decisions and actions, even when you were asked or told to act by someone else.
  1. In practiceA practical nurse on a medical unit is caring for a stable client whose breathing becomes laboured, with an SpO2 that falls from 95% to 88%. The nurse stays with the client, raises the head of the bed, applies the oxygen ordered as needed and calls the RN to the bedside, because the client's needs have moved beyond predictable care.
  2. Where questions turnContinuing to manage a client alone after the client has become unstable, or refusing to act at all when a first safety action is within the practical nurse's role.
Practise this activity

3Draw on evidence, technology and policies to improve care

  • Use credible, current resources: agency policies and procedures, a current drug reference, the pharmacist, best practice guidelines and the electronic health record.
  • When a policy and a coworker's habit disagree, follow the policy; if the policy seems out of date or unsafe, raise it with the manager rather than ignoring it.
  • Use technology as designed: barcode scanning, smart pump libraries and electronic alerts are safety checks, and overriding them needs a clear reason and documentation.
  • Evidence changes practice; best practice guidelines and evidence summaries support decisions such as fall prevention, pressure injury prevention and pain management.
  • Professional interpreter services, patient education materials and community resources are tools of care too; use them instead of relying on family members to interpret.
  1. In practiceA practical nurse unfamiliar with a new wound dressing finds that two coworkers describe different ways to apply it. The nurse checks the agency's procedure and the product instructions and asks the wound care nurse, because the approved procedure, not a coworker's routine, sets the standard.
  2. Where questions turnRelying on memory, a coworker's routine or an internet search when an approved policy, drug reference or specialist is available.
Practise this activity

4Speak up for what clients need and are entitled to

  • Advocacy means speaking up for the client's interests, safety and wishes, especially when the client cannot do so alone.
  • Clients have the right to information about their care, to ask questions, to refuse treatment, to a second opinion and to have their privacy and dignity respected.
  • When a client does not understand a procedure, has unrelieved pain or is not being heard, bring it to the RN or primary health care provider promptly with specific data.
  • Advocate through the right channels: the care team first, then the manager, patient relations or an ethics resource if the concern is not resolved.
  • Advocacy supports the client's own choices; it does not replace them with what the nurse or family thinks is best.
  1. In practiceA resident with mild cognitive impairment tells the nurse she does not want the bath that her son insists she take every morning. The nurse confirms the resident's preference, offers another time and reports the issue to the RN so the care plan reflects the resident's choice, because the resident's wishes come before the family's routine.
  2. Where questions turnSiding with the family or the team for convenience instead of making sure the client's own wishes and needs are heard.
Practise this activity

5Give and take report on the clients you are assigned

  • A handoff transfers responsibility for the client; use a structured format such as SBAR or an agency tool so nothing important is missed.
  • Include the client's current status and any change, pending tests and results, recent medications and those due, safety risks (falls, allergies, isolation) and the plan.
  • Give and receive report where it cannot be overheard; bedside handoff can include the client, who can correct or add information.
  • The receiving nurse asks questions, reads back critical items and checks unstable clients first; responsibility passes only when the handoff is complete.
  • Focus on facts and changes, not opinions or labels about the client.
  1. In practiceAt shift change, the outgoing nurse reports that a client returned from surgery 2 hours ago, has a blood glucose result pending and voided only once. The receiving nurse repeats back the pending result and the voiding concern and checks the client first, because these are the items most likely to need action.
  2. Where questions turnAccepting a vague or incomplete handoff and assuming the outgoing nurse dealt with pending results or changes.
Practise this activity

6Start, review and revise the client's care plan

  • The care plan follows the nursing process: data collection, nursing problem, goals with the client, interventions, and evaluation against the goals.
  • Goals are client-centred, specific, measurable and time-limited (for example, walks 30 m with a walker three times a day by Friday).
  • Evaluate regularly: if the goal is met, update the plan; if it is not met, look for the reason, revise the interventions and involve the client.
  • Practical nurses initiate and update plans for clients with predictable needs; for complex or changing needs, collaborate with the RN on the plan.
  • Document changes in the plan so every shift and every team member follows the same approach.
  1. In practiceA client recovering from a hip replacement still needs two people to transfer after a week, though the goal was transfer with one person by day 5. The nurse reviews what has changed, discusses it with the client and physiotherapist and revises the goal and interventions, because a goal that is not met calls for reassessment, not repetition.
  2. Where questions turnContinuing the same interventions after the evaluation shows the goal was not met, or writing goals that cannot be measured.
Practise this activity

7Notice ethical dilemmas and respond to them properly

  • An ethical dilemma exists when two ethical principles conflict (for example, autonomy and beneficence) and no choice fully satisfies both.
  • Recognize the dilemma, gather the facts, identify who is affected and the client's own values, then consider the options and their consequences.
  • Use agency resources: the RN, the manager, an ethics consultation service or committee and the code of ethics.
  • A nurse with a conscientious objection informs the employer early, does not abandon the client and ensures care continues with another provider.
  • Respect a capable client's informed choice even when the nurse disagrees with it.
  1. In practiceA capable client with advanced lung disease refuses a feeding tube, and her daughter begs the nurse to persuade her. The nurse recognizes the conflict between the daughter's wish to prolong life and the client's autonomy, supports the client's informed decision and requests a family meeting with the team, because the capable client decides.
  2. Where questions turnTaking sides or acting alone on a dilemma instead of naming it and using the team and ethics resources.
Practise this activity

8Act in line with the nursing code of ethics, fairly and without causing harm

  • Give care that is respectful, nondiscriminatory and free of bias regardless of a client's age, race, culture, religion, ability, income, diagnosis, sexual orientation or gender identity.
  • Do no harm: keep clients safe, tell the truth, admit and report errors, and avoid actions that place your interests above the client's.
  • Keep professional boundaries: no personal relationships, gifts of value, financial dealings or social media connections with clients.
  • Keep promises and be honest; never deceive a client, even to make care easier.
  • Notice your own biases and keep them out of care decisions such as pain management.
  1. In practiceA client who uses substances asks for pain medication, and a coworker comments that the client is just drug seeking. The nurse assesses the pain like any other client's, gives the prescribed analgesic and reports the pain level, because bias must not change the care a client receives.
  2. Where questions turnLetting a personal judgment about a client (substance use, behaviour, background) lower the standard of care given.
Practise this activity

9Decide the order in which clients get care

  • Use airway, breathing and circulation first, then safety and Maslow's hierarchy: physiological needs before psychosocial ones, actual problems before potential ones.
  • An acute, unexpected change outranks a chronic or expected finding; compare each finding with the client's baseline.
  • Unstable clients come first; the practical nurse gives the first safety actions and calls the RN or primary health care provider at once.
  • Time-critical tasks (a hypoglycemia treatment, a time-sensitive medication, a client at risk of falling now) come before routine care.
  • When choosing whom to see first, ask which client could be harmed most by waiting.
  1. In practiceAt the start of a shift in long-term care, the nurse learns that one resident has a capillary glucose of 3.1 mmol/L and is sweaty, another wants pain medication for chronic knee pain, and a third needs a dressing change. The nurse treats the low glucose first, because it is an acute threat that worsens within minutes.
  2. Where questions turnChoosing the client with the loudest request or the longest task instead of the one with the most urgent physiological need.
Practise this activity

10Plan your workload so time is used well

  • Plan the shift at the start: list fixed-time tasks (scheduled medications, tests, treatments) and fit flexible tasks around them.
  • Cluster care so one visit covers several needs, and gather supplies before entering the room.
  • Assign suitable tasks to UCPs early so they can plan their time too, and check progress during the shift.
  • Reprioritize when something changes; a new admission or a deteriorating client resets the plan.
  • Limit interruptions during medication preparation and document as close to the time of care as possible.
  1. In practiceA nurse on a rehabilitation unit has five clients, two scheduled medications at 0900 and a client going to physiotherapy at 1000. The nurse gives the 0900 medications, prepares the client for physiotherapy and saves the routine charting for after 1000, because time-fixed tasks come first.
  2. Where questions turnDoing tasks in the order they come to mind instead of planning around fixed times and clustering care.
Practise this activity

11Assign care to others, such as unregulated care providers, and oversee it

  • Assign a UCP only tasks that are within the UCP's role and agency policy, that the UCP is competent to do, and for a client whose condition is stable and predictable.
  • UCPs can help with hygiene, feeding a client without swallowing problems, ambulation and transfers of stable clients, routine vital signs and measuring intake and output.
  • Do not assign assessment, teaching, care plan decisions or the care of an unstable or newly changed client. Whether a UCP may give or help with medications depends on the setting, the province and employer policy; check before assigning it.
  • Give clear direction: what to do, for whom, by when, what to report right away (for example, an SpO2 below a set value) and any special precautions.
  • Supervise: check the work, follow up on reports, give feedback, and remember that the nurse stays accountable for the decision to assign.
  1. In practiceThe nurse asks a UCP to walk a stable client who walked with the UCP yesterday, and to report at once if the client becomes dizzy or short of breath. The nurse keeps the client with new confusion for herself, because new confusion needs a nurse's assessment.
  2. Where questions turnAssigning a task because it seems simple, without checking whether the client is stable and whether the task needs nursing judgment.
Practise this activity

12Judge when a referral or consult is needed and get the orders for it

  • Recognize when a client's needs call for another discipline: swallowing problems (speech-language pathologist), weight loss (dietitian), mobility and falls (physiotherapist), daily living tasks at home (occupational therapist), finances or housing (social worker), spiritual distress (spiritual care).
  • Many referrals need an order from the primary health care provider or follow an agency protocol; know which apply in your setting.
  • Bring the specific findings that support the referral when you ask for the order.
  • Involve the client: explain the reason for the referral and ask for agreement.
  • Follow up to see whether the referral was completed and add the recommendations to the care plan.
  1. In practiceA resident coughs during most meals and has had two chest infections this year. The nurse reports the coughing to the RN and primary health care provider and asks for a speech-language pathology referral, because coughing during meals suggests unsafe swallowing.
  2. Where questions turnTreating a recurring problem alone when the client needs the expertise of another discipline.
Practise this activity

13Take and transcribe orders from prescribers

  • Every order needs the client's name and identifiers, the date and time, the drug or treatment, the dose, route and frequency, and the prescriber's signature.
  • Accept verbal or telephone orders only when the agency allows it and the situation requires it: write the order down, read it back to confirm, document and have it signed within the time policy sets.
  • Clarify any order that is incomplete, unclear, unusual or unsafe with the prescriber before acting on it.
  • Transcribe exactly as written and check the transcription against the original, using a second check where policy requires it.
  • Use approved abbreviations only; spell out terms on the do-not-use list such as units and daily.
  1. In practiceA primary health care provider phones an order for a new antibiotic dose while the nurse is at the station. The nurse writes it down, reads the whole order back, receives the provider's confirmation and enters it as a telephone order for the provider to sign, because read-back prevents errors in spoken orders.
  2. Where questions turnActing on an order that is incomplete or unclear, or skipping the read-back of a verbal order.
Practise this activity

14Obtain the client's consent before care or a procedure and explain what it involves

  • Informed consent for a procedure is obtained by the person who will perform it, who explains its nature, benefits, risks and alternatives; the nurse may witness the signature and confirm the client understands.
  • Consent depends on capacity, not a fixed age: a capable client, including a capable young person, may give or refuse consent.
  • Routine nursing care relies on implied or verbal consent; explain what you are about to do and stop if the client refuses.
  • Consent is voluntary and can be withdrawn at any time; if a client has questions or doubts, the procedure waits and the person performing it is told.
  • Use a professional interpreter when language is a barrier; family members, especially children, are not appropriate interpreters for consent.
  1. In practiceBefore a scheduled colonoscopy, a client tells the nurse she is not sure what the test involves. The nurse does not witness the signature yet and asks the physician to return and explain, because consent is not informed until the client understands.
  2. Where questions turnWitnessing a signature when the client has unanswered questions, or trying to explain the risks of a procedure the nurse will not perform.
Practise this activity

15Build the client's advance directives into the care plan

  • An advance directive records a capable person's wishes for future care and may name a substitute decision-maker; it guides care when the client can no longer decide.
  • Ask on admission whether the client has an advance directive, place a copy in the record and make sure the care plan reflects it.
  • A capable client can change wishes at any time; record the change and inform the RN and primary health care provider.
  • A do not resuscitate (DNR) order is a provider's order about CPR only; the client still receives all other care, comfort and treatments the client wants.
  • Substitute decision-makers decide according to the wishes the client expressed while capable, not their own preferences.
  1. In practiceA resident with a DNR order develops a fever and cough. The nurse reports the findings to the primary health care provider and gives the treatments ordered, because DNR means no CPR, not no care.
  2. Where questions turnTreating a DNR order as an order to withhold all care, or following a family member's wishes over the client's documented wishes.
Practise this activity

16Work with other disciplines on the client's care

  • Each team member brings expertise: pharmacist (medications), physiotherapist and occupational therapist (function), dietitian (nutrition), respiratory therapist (breathing support), social worker (resources), spiritual care.
  • Communicate clearly and respectfully using structured tools such as SBAR, especially when reporting a change to a primary health care provider.
  • Share relevant findings with the right team member at the right time; do not wait for rounds when a finding needs action.
  • Take part in team meetings and care conferences, bringing the client's view and the nursing data.
  • Team decisions are recorded so that every discipline works toward the same goals.
  1. In practiceA client's new prescription for an anticoagulant appears to interact with an herbal product the client takes. The nurse holds the herbal product per policy, calls the pharmacist and informs the primary health care provider, because the pharmacist has the expertise on interactions.
  2. Where questions turnTrying to solve a problem alone that belongs to another discipline, or reporting a change without the specific data the team needs.
Practise this activity

17Take part in resolving disagreements

  • Address conflict early, directly and privately with the person involved, using calm "I" statements and facts.
  • Listen to understand the other view, focus on the client's needs and look for a solution both can accept.
  • Escalate to the manager when direct discussion fails, when client safety is at risk, or when the conflict involves harassment.
  • With clients and families, acknowledge feelings, stay calm, set respectful limits and involve the RN, manager or patient relations when needed.
  • Never argue in front of clients or involve clients in staff conflicts.
  1. In practiceA UCP repeatedly ignores the nurse's requests to reposition a client every 2 hours. The nurse speaks with the UCP privately, explains the client's risk, asks what is getting in the way and agrees on a plan, then involves the manager if the problem continues.
  2. Where questions turnGoing straight to the manager, or avoiding the conflict, when a private and direct conversation is the first step.
Practise this activity

18Know the limits of your own skills and ask for help

  • Know your limits: do not perform a skill or use equipment you have not been taught and found competent to use.
  • Ask for help, education or supervision before acting; say so clearly to the RN or manager.
  • When floated to an unfamiliar unit, accept the parts of the assignment you are competent to perform and tell the charge nurse which parts you are not.
  • When a client's condition goes beyond your competence, consult the RN or transfer care; asking for help is a professional responsibility, not a weakness.
  • Fatigue, illness and impairment also limit competence; report them before working.
  1. In practiceA practical nurse is asked to set up a type of infusion pump never used before. The nurse tells the charge nurse, asks to be shown and supervised, and does not start the infusion alone, because competence must come before practice.
  2. Where questions turnPerforming an unfamiliar skill to avoid looking incompetent, or refusing the whole assignment instead of saying what you can and cannot do.
Practise this activity

19Make legally required reports, such as suspected abuse or reportable disease

  • The duty to report a child who may need protection is personal: a nurse with reasonable grounds reports directly to child protection services and may not rely on someone else to report.
  • Reasonable suspicion is enough; you do not need proof, and you do not investigate.
  • Suspected abuse or neglect of a resident in a care facility is reported at once as legislation and policy require, and the resident is protected first.
  • Certain communicable diseases must be reported to public health; follow the agency's process so the report is made.
  • Document objective findings and the client's own words, and inform the manager per policy.
  1. In practiceA toddler brought to a clinic has bruises in several stages of healing on the back and upper arms, and the parent's explanation keeps changing. The nurse records the findings and the parent's words and reports directly to child protection services, as well as informing the manager, because the duty to report rests with the nurse who has the suspicion.
  2. Where questions turnTelling only the manager or waiting for proof, instead of reporting a reasonable suspicion directly.
Practise this activity

20Carry out admissions, transfers and discharges safely

  • Admission: identify the client with two identifiers, orient to the room and call bell, record allergies, belongings and the advance directive, and start medication reconciliation.
  • Transfer: give a structured report to the receiving nurse, send the record and medications as policy requires, and make sure the client is stable enough to move.
  • Discharge: confirm the order, reconcile medications, teach and check understanding with teach-back, give written instructions and arrange follow-up.
  • A capable client who wants to leave against medical advice cannot be held: inform the primary health care provider, explain the risks and follow the agency's process.
  • Document the time, condition, teaching and where and with whom the client went.
  1. In practiceA client being discharged after pneumonia has a new inhaler and an antibiotic. The nurse reviews each medication against the home list, asks the client to show how to use the inhaler and explain when to take the antibiotic, and confirms the follow-up appointment, because teach-back shows whether teaching worked.
  2. Where questions turnDischarging a client without reconciling medications or checking understanding, or trying to keep a capable client from leaving.
Practise this activity

21Teach clients and staff what clients' rights and responsibilities are

  • Clients have the right to information, privacy, dignity, safe care, consent and refusal, access to their own health record and a way to raise complaints.
  • Residents of long-term care have rights set out in a residents' bill of rights, which is posted and explained to residents and families.
  • Clients also have responsibilities: giving accurate information, taking part in care decisions and respecting others.
  • Teach staff, including UCPs and students, how rights apply in daily care, such as knocking before entering and asking before helping.
  • Explain how to raise a concern or complaint, and do not discourage it.
  1. In practiceA new resident's daughter asks whether her mother can refuse a daily activity. The nurse explains that her mother has the right to choose her activities and refuse care, shows her the posted residents' rights, and tells her how to raise concerns with the team.
  2. Where questions turnTreating rights as information for clients only, when staff behaviour is where rights are protected or broken.
Practise this activity

22Take part in quality and performance improvement work

  • Quality improvement looks at systems, not blame: incident and near-miss reports show where processes fail.
  • Complete a safety or incident report for any error, near miss or unexpected event; the report is not part of the client's record and is not noted in it.
  • Take part in audits (hand hygiene, falls, pressure injuries), data collection and unit projects.
  • Improvement cycles test a small change, measure the result, then adopt, adapt or drop it (Plan, Do, Study, Act).
  • Suggest improvements through the unit's channels when you notice a recurring problem.
  1. In practiceA nurse notices that two clients on the unit nearly received each other's medications because their names are alike. The nurse completes a near-miss report and suggests a name alert, because reporting near misses lets the unit fix the system before harm occurs.
  2. Where questions turnThinking a near miss needs no report because no one was harmed, or mentioning the incident report in the client's chart.
Practise this activity

23Document care using accepted terms and abbreviations

  • Use only the abbreviations, symbols and terms your agency approves; avoid those on do-not-use lists, such as U for unit, QD for daily and trailing zeros (1.0 mg).
  • Always use a leading zero before a decimal (0.5 mg) and write units in full when there is any risk of confusion.
  • Document facts, measurements and the client's own words, not opinions or labels.
  • Correct errors as policy directs, keeping the original entry readable; never erase, delete or change past entries; add late entries as late entries.
  • Use the 24-hour clock and the agency's standard terms so every reader understands the record the same way.
  1. In practiceA nurse writing a note about insulin writes "4 units" rather than "4 U", and records that the client "ate 25% of lunch" rather than "ate poorly", because spelled-out units and measured terms prevent misreading.
  2. Where questions turnUsing a familiar but unapproved abbreviation, or a vague term, that another reader could misinterpret.
Practise this activity

24Step in and report when another provider's practice is unsafe

  • When any provider's practice puts a client at risk, protect the client first: stop or interrupt the action if you can do so safely.
  • Then report the concern promptly to the manager or the person in charge, with facts.
  • A coworker who appears impaired is removed from client care right away by reporting to the person in charge.
  • Some concerns must also be reported to the regulatory college as legislation requires (for example, sexual abuse of a client by a regulated health professional).
  • Document and report through the proper channels; do not confront in front of clients or discuss it with others.
  1. In practiceA nurse sees a coworker about to hang a blood product without checking the client's identification. The nurse stops the coworker, insists on the two-person check and then reports the event to the charge nurse, because the client must be protected before the concern is reported.
  2. Where questions turnReporting the unsafe act afterward without stepping in when the client was about to be harmed, or ignoring it to keep the peace.
Practise this activity

25Include the client in decisions about their care

  • Clients are partners in care: ask about their goals, preferences and values before planning.
  • Give information in plain language and check understanding so the client can make an informed choice.
  • Offer real choices where they exist (timing of care, order of tasks, options for treatment).
  • Respect an informed refusal; explain the consequences, report it and document it.
  • Involve family or a substitute decision-maker only as the client wishes, or when the client cannot decide.
  1. In practiceA client with diabetes wants to keep eating at her usual mealtimes, which differ from the unit's schedule. The nurse discusses timing of her insulin and meals with her and the team, so the plan fits her routine, because a plan the client helped shape is one she is more likely to follow.
  2. Where questions turnMaking decisions for a capable client because it seems faster or safer, or speaking only to the family.
Practise this activity

26Review and build your own competence through reflection and learning

  • Practical nurses are responsible for keeping their own competence current through their regulator's quality assurance program.
  • Reflect on practice regularly: identify strengths and learning needs, set goals and make a learning plan.
  • Seek feedback from peers and supervisors and learn from incidents.
  • Use learning opportunities: in-services, courses, reading, professional association activities and certification.
  • Keep records of learning activities as the regulator requires.
  1. In practiceAfter a client's condition worsened during the night, a nurse realizes she was unsure how to interpret a rising early warning score. She adds that skill to her learning plan, attends the unit's in-service and asks the educator for practice, because self-reflection turns experience into learning.
  2. Where questions turnWaiting for the employer to identify learning needs, when keeping competence current is the nurse's own duty.
Practise this activity

27Support and teach new staff and students

  • Welcome new staff and students, orient them to the unit, policies and routines, and be available for questions.
  • Students work within their program's rules and their level of learning; confirm which skills they may perform and supervise them.
  • The nurse stays accountable for the client's care when a student or new staff member is involved.
  • Give feedback promptly and privately, describing specific behaviour, and encourage questions.
  • Model safe and ethical practice; new staff learn as much from what they see as from what they hear.
  1. In practiceA practical nursing student asks to give an injection she has practised only in the lab. The nurse checks that her program allows it at her level, reviews the steps with her, and stays at her side while she gives it, because the nurse remains accountable for the client.
  2. Where questions turnLetting a student perform a skill unsupervised or one outside the program's rules, or assuming new staff already know unit policies.
Practise this activity

28Draw on Indigenous ways of knowing and healing when caring for Indigenous clients

  • Cultural safety is defined by the client: care in which the Indigenous client feels respected and free of racism and discrimination.
  • Ask each client about their own beliefs, practices and preferences instead of assuming them from identity.
  • Support traditional practices the client asks for, such as smudging, ceremony, traditional medicines or an Elder's visit, using the agency's policy and Indigenous health or liaison services.
  • Ask about traditional medicines, record them and share them with the primary health care provider and pharmacist so possible interactions are checked, without dismissing them.
  • Recognize the effects of colonialism and residential schools on trust in health care, use a trauma-informed approach and include family and community as the client wishes.
  1. In practiceAn older First Nations client admitted with heart failure asks if his granddaughter can bring sage for a smudge. The nurse thanks him, checks the agency's smudging policy, contacts the Indigenous liaison to arrange a suitable space and adds the practice to his care plan, because supporting his practice is part of culturally safe care.
  2. Where questions turnAssuming what an Indigenous client wants based on identity, or refusing a traditional practice without checking policy and resources.
Practise this activity

29Give fair care with equal access for every client, whatever their sexual orientation or gender identity or expression

  • Every client receives the same respectful, equitable care whatever their sexual orientation or gender, and however they express it.
  • Ask privately for the client's chosen name and pronouns, use them consistently and record them where the agency's record allows.
  • Collect information about sexual orientation, gender identity or anatomy only when it is relevant to care, and keep it confidential.
  • Respect the client's choice of support person or substitute decision-maker, including a same-sex partner or chosen family.
  • Challenge discriminatory comments or practices by colleagues and report them as policy requires.
  1. In practiceA transgender woman is admitted for surgery, and her identification still shows her previous name. The nurse asks privately what name and pronouns she uses, records them as policy allows, uses the legal name only where identification checks require it, and makes sure the room assignment respects her gender identity.
  2. Where questions turnUsing a client's legal name or sex assigned at birth in front of others when it is not needed for safety, or asking intrusive questions not related to care.
Practise this activity

Key terms

Scope of practice
The activities a practical nurse is educated, authorized and competent to perform, limited further by employer policy and individual competence.
Circle of care
The people who provide care to a client and may share the client's information for that care without express consent.
Unregulated care provider (UCP)
A paid care worker who is not regulated by a health college, such as a personal support worker or health care assistant.
Assignment
Giving a staff member care tasks within that person's role and competence, while the nurse remains accountable for the decision.
Supervision
Giving direction, checking progress and evaluating the care others provide.
SBAR
Situation, Background, Assessment, Recommendation: a structured way to report or hand off a client.
Informed consent
A capable client's voluntary agreement after learning the nature, benefits, risks and alternatives of a treatment.
Capacity
The ability to understand information about a decision and appreciate its likely consequences.
Substitute decision-maker
The person who makes care decisions for a client who is not capable, following the client's known wishes.
Advance directive
A record of a capable person's wishes for future health care, which may name a substitute decision-maker.
Do not resuscitate (DNR)
A primary health care provider's order that CPR will not be attempted; all other care continues.
Medication reconciliation
Comparing the client's medication list at each transition of care to find and resolve differences.
Near miss
An event that could have harmed a client but did not, because it was caught or by chance.
Cultural safety
Care that the client experiences as respectful and free of racism and discrimination.
Conscientious objection
A nurse's refusal, on grounds of conscience, to take part in a lawful treatment, while making sure care continues.

After this guide: You can decide whom to see first, what to assign to a UCP, when to consult the RN or primary health care provider, and how to protect a client's privacy, consent, rights and wishes within the practical nurse's scope, the law and the code of ethics.

Practise Management of Care