Ethical Practice Teaching activities and resources
This section provides educators with knowledge and skills required to support nurses to assist persons with a mental health illness and addiction in making informed decisions about their care and symptom management in an ethical and culturally competent manner.
At the end of this section, the educator will enable the students to achieve the following:
- Have increased knowledge of nursing ethics, including the CNA (2008) Code of Ethics for Registered Nurses.
- Have increased knowledge of cultural competency and cultural safety, and relate the concepts to the role of the nurse.
- Recognize that nurses have a professional ethical responsibility to advocate for persons with mental health and addiction disorders.
- In a clinical setting for students—establish a safe and respectful environment for voluntary and involuntary patients seeking or receiving treatment for a mental illness and addiction; and demonstrate cultural competency and cultural safety.
Every nurse is responsible for upholding ethical practice standards. In Canada, the Canadian Nursing Association’s (2008) Code of Ethics for Registered Nurses provides guidance regarding ethical values for nurses and their client’s health-care needs. This resource is intended for all context and domains of nursing practice, and is also an excellent resource for nurses working with clients who have mental health or illness conditions and addiction.
Because “the expression of mental illness is heavily determined by culture” (Kent-Wilkinson, 2010, p. 31), it is imperative that nursing students understand and demonstrate cultural competency and cultural safety when caring for individuals with mental illness and addiction. Cultural competency is “the application of knowledge, skills, attitudes and personal attributes required by nurses to provide appropriate care and services in relation to the cultural characteristics of their client” (CNA, 2010, p. 1). Nurses first develop an awareness of one’s self and understand that cultural differences exist. It is also important to be aware that one’s own culture is not superior to that of others. Nurses caring for people with mental illness with a whole-person and recovery-oriented view must also be willing to learn about other people’s cultures, and respect the differences in culture and be willing to incorporate that knowledge into practice and educational curricula (Kent-Wilkinson, 2015).
Due to the complex nature of mental illness, nurses may face ethical dilemmas when working with this population, such as issues relating to client autonomy and restraint. Nursing students need to be well-prepared for a variety of ethical dilemmas, including voluntary and involuntary care, that will arise when working with people with mental illness and addiction. They should be taught the skills and knowledge to proactively and reactively manage the unpredictable.
For more information, see Resources in this section.
Teaching and Learning Activities
The following are teaching and learning activities that can be employed in the classroom to further support nurses in the integration of theory, principles and best practices related to ethical practice.
- Review the CNA Code of Ethics (2017) and local College of Nurses documents pertaining to ethics
- Define culture competency and cultural safety
- Facilitate group discussion using questions such as:
- What does the nurse do and at what point does the nurse have an obligation to do regarding (insert particular situation)?
- Bathing/hygiene: what is the importance of bathing and the patients’ rights to make choice and decision regarding bathing?
- Eating: what’s the importance of eating disorders and refusing right to eat?
- Guest lecturer—person with lived experience (Appendix H), and Rights Advisors
- Case studies—Section 9.3
- Practice application
- Review Safewards by Len Bowers
Learner Engagement Questions
The following are thought-provoking and engaging learner questions that can be used to further discussions with nursing students regarding ethical practice. These questions can be used either to stimulate discussion, engage students in critical thinking or be tied to class assignments and/or reflection exercises.
- How can nurses become more culturally competent?
- How would you balance off rights and laws/legal obligation?
- Does addiction cause mental illness?
- What is the relationship between mental health and addiction?
- When is the use of coercion ever okay (e.g., medication, hunger strikes passes, bathing, eating, etc.)?
- What does the nurse do when patients refuse to bath, eat, or take their medication?
- How can the nurse engage clients therapeutically?
- How does this link back to assessments (i.e., risk and strengths and health head to toe)?
Evaluation and Self-reflection
The following tools can be used to evaluate students in their understanding and application of therapeutic relationships.
- Clinical evaluation
- Guided discussion
Self-reflection questions include:
- What are your thoughts regarding self-disclosure of addiction or mental illness in clinical practice? In school?
- When is it appropriate to self-disclose? When is it inappropriate?
- What are your personal beliefs about addiction, substance use and how it affects mental wellness or mental illness?
- How do you apply the Code of Ethics in your practice?
- Do you think you are culturally aware?
- How much of your cultural awareness is based on stereotyping, influence from media or personal experience?
- Canadian Nursing Association’s (2008) Code of Ethics
- College of Nurses of Ontario Ethics (2009)
- Aboriginal Nurses Association of Canada, Canadian Association of Schools of Nursing, & Canadian Nurses Association. (2009). Cultural competence and cultural safety in nursing education. Ottawa, ON: ANAC.
- Canadian Nurses Association. (2010). Cultural Competence Position Statement.
- Canadian Nurses Association. (2004). Promoting Continuing Competence for Registered Nurses.
- Kent-Wilkinson, A., Blaney, L., Groening, M., Santa Mina, E., Rodrigue, C., & Hust, C. (2016). CFMHN’s 3rd position paper 2016: Mental health and addiction curriculum in undergraduate nursing education in Canada. Prepared by members of the Canadian Federation of Mental Health Nurses’ Education Committee. Toronto, ON: CFMHN.
The following films demonstrate ethical dilemmas that can be used to educate nursing students regarding ethics. Consider using the self-reflection questions to highlight themes that can be found in the films listed below.
- Blue Jasmine (2013). Cate Blanchett plays Jasmine, a rich socialite who’s life falls apart when her husband Hal dies and she is left destitute.
- King (1991) Robin Williams plays Parry, a teacher who becomes mentally ill after he witnesses his wife being killed in a restaurant massacre. Unable to recuperate from the tragic incident, Perry becomes a deluded homeless man. He believes that he is a knight sent by God on a sacred quest.
- 28 Days (2000) Sandra Bullock plays Gwen Cummings, a newspaper columnist obliged to enter rehabilitation for alcoholism.
- Austin & Boyd (Eds) (2015) Psychiatric & Mental Health Nursing for Canadian Practice (Third Canadian Edition).
- Chapter 3: Kent-Wilkinson (2015) The Context of Mental Health Care: Cultural, Socio-economical and Legal.
- Chapter 7: Austin (2015). Ethical Psychiatric and Mental Health Nursing Practice.
- Halter (2014) Varcaroli’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (First Canadian Edition).
- Chapter 7: Mordoch. (2014)Cultural implications for psychiatric mental health nursing.
- Chapter 8: Pollard (2014)Ethical Responsibilities and Legal Obligations for psychiatric mental Health Nursing Practice.
- Baba, L. (2013). Cultural safety in First Nations, Inuit and Métis public health: Environmental scan of cultural competency and safety in education, training and health services. Prince George, BC: National Collaborating Centre for Aboriginal Health.
- Browne, A. J., Varcoe, C., Smye, V., Reimer-Kirkham, S., Lynam, M. J., & Wong, S. (2009). Cultural safety and the challenges of translating critically oriented knowledge in practice. Nursing Philosophy, 10(3), 167–179.
- Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa, ON: Author.
- Canadian Nurses Association. (2009). Cultural competence and cultural safety in nursing education: A framework for First nations, Métis and Inuit Nursing. Aboriginal Nurses Association [ANA], Canadian Association of Schools of Nursing [CASN], and Canadian Nurses Association [CNA]. Retrieved from https://cna-aiic.ca/~/media/cna/page-content/pdf-en/first_nations_ framework_e.pdf
- Canadian Nurses Association. (2009). Global health and equity (Position statement). Retrieved from http://www.cna-aiic.ca/en/advocacy/policy-support-tools/cna-position-statements/
- Canadian Nurses Association. (2010). Position Statement - Promoting cultural competence in nursing. https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/ps114_cultural_ competence_2010_e.pdf?la=en
- College of Nurses of Ontario. (2009). Practice Standard: Ethics. Retrieved from: http://www.cno. org/en/learn-about-standards-guidelines/educational-tools/learning-modules/ethics/
- Engel, J., & Prentice, D. (2013). The ethics of interprofessional collaboration. Nursing Ethics, 20(4), 426–435. http://dx.doi.org/10.1177/0969733012468466
- Ewashen, C., McInnis-Perry, G., & Murphy, N. (2013). Interprofessional collaboration in-practice: The contested place of ethics. Nursing Ethics, 20(3), 325–335.
- Hart-Wasekeesikaw, F., & Gregory, D. (2009). Cultural competence and cultural safety in First Nations, Inuit and Métis nursing education: An integrated review of the literature. Institutional Repository, University of Lethbridge, Lethbridge, AB.
- Halter, M. J. (2014). Psychiatric mental health nursing standards of practice, code of ethics, beliefs and values. In M. J. Halter, Varcarolis’s Canadian psychiatric mental health nursing: A clinical approach. C. L. Pollard, S. L. Ray, & M. Haase (Eds.), (First Canadian ed., appendix A, pp.735–736). Toronto, ON: Elsevier Canada.
- Kent-Wilkinson, A. (2015). The context of mental health care: Cultural, socioeconomic, and legal. In W. Austin & M. A. Boyd (Eds.), Psychiatric & mental health nursing for Canadian practice (3rd ed., Chapter 3, pp. 25–41). Philadelphia, PA: Wolters Kluwer.
- Kersey-Matusiak, G. (2012). Culturally competent care: Are we there yet? Nursing Management (Springhouse), 43(4), 34-39.
- Kirmayer, L. J. (2012). Cultural competence and evidence-based practice in mental health: Epistemic communities and the politics of pluralism. Social Sciences & Medicine, 75(2), 249-256.
- Pollard, C. L. (2014). Ethical responsibilities and legal obligations for psychiatric mental health nursing practice. In M. J. Halter, Varcarolis’s Canadian psychiatric mental health nursing: A clinical approach. C. L.
- Pollard, S. L. Ray, & M. Haase (Eds.), (First Canadian ed., chapter 8, pp. 114–130). Toronto, ON: Elsevier C Canada.
- Registered Nurses’ Association of Ontario. (2007). Embracing cultural diversity in health care: Developing cultural competence. Toronto, ON: Registered Nurses’ Association of Ontario.
- Richardson, D. (2008). Cultural safety: An introduction. Paediatric Nursing, 20(2), 39–43.
- Srivastava, R. (Ed.) (2007). The healthcare professional’s guide o clinical cultural competence. Toronto, ON: Mosby Elsevier.