No abstract

Recent changes to the Criminal Code of Canada have resulted in the right of competent adult Canadians to request medical assistance in dying (MAID). Healthcare professionals now can participate if the individual meets specific outlined criteria. There remains confusion and lack of knowledge about the specific role of nurses in MAID. MAID is a controversial topic and nurses may be faced with the challenge of balancing the duty to provide routine care, with moral reservations about MAID. The role of a nursing leader is to support nurses by ensuring they have the knowledge they require to care for patients requesting the service, whether or not the nurse is directly involved in the MAID process. The moral dilemmas raised by MAID provide an opportunity to look at a relational ethics approach to nursing leadership both for MAID and other difficult situations that arise in nursing practice. Relational ethics is a framework that proposes that the ethical moments in healthcare are based on relationships and fostering growth, healing, and health through the foundational concepts of mutual respect, engagement, embodiment, and environment. This article will use a relational ethics framework to examine how nursing leadership can support nurses who care for patients requesting MAID.

Continuous improvement efforts, recognized in much literature as Lean management techniques have been used in efforts to improve efficiency in democratic health care contexts for some time to varying degrees of success. The complexity of the health care system is magnified by the sheer number of processes and sub processes required to deliver value within a bureaucratic environment, while maintaining some level of compassionate and personalized care. There is inherent tension between what is required to be efficient and what is required to be caring and this conflict presses against Lean practice at the level of delivery.Administration and care intersect at the point of the patient's experience. In order to achieve the dual goals of improved value and lower costs, the application of Lean thinking for meaningful health care reform must acknowledge the fundamental dichotomy between the impersonal tasks required to provide health services, and human interactions. Meaningful health care reform requires an acknowledgement of this distinction, currently not recognized in literature. While administrative process improvements are necessary, they are insufficient to achieve a sustainable and caring health care system. Lean thinking must be applied differently for administrative processes and patient care encounters, because these are fundamentally different processes. In this way, Lean principles will effectively contribute to sustainable health system improvements.

Jennifer Dunsford, RN, BN, is an oncology nurse and coordinator of quality and patient safety at

The duty to provide care is foundational to the nursing profession and the work of nurses.Unfortunately, violence against nurses at the hands of recipients of care is increasingly common. While employers, labor unions, and professional associations decry the phenomenon, the decision to withdraw care, even from someone who is violent or abusive, is never easy. The scant guidance that exists suggests that the duty to care continues until the risk of harm to the nurse is unreasonable, however, "reasonableness" remains undefined in the literature. In this paper, I suggest that reasonable risk, and the resulting strength of the duty to provide care in situations where violence is present, hinge on the vulnerability of both nurse and recipient of care. For the recipient, vulnerability increases with the level of dependency and incapacity. For the nurse, vulnerability is related to the risk and implications of injury. The complex interplay of contextual vulnerabilities determines whether the risk a nurse faces at the hands of a violent patient is reasonable or unreasonable. This examination will enhance our understanding of professional responsibilities and can help to clarify the strengths and limitations of the nurse's duty to care.