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SJHH / Patients & Visitors/ Code of Conduct/Standards of Behaviour

Code of Conduct/Standards of Behaviour

1.0 Purpose & Goals

St. Joseph’s Healthcare Hamilton’s (SJHH) Mission commits us to live the legacy of the Sisters of St. Joseph Hamilton by providing compassionate, sensitive care to our patients and their families. In order to live this mission and to operate effectively, SJHH has established standards of conduct and performance aligned with SJHH’s Values and C.A.R.E. Standards of Behaviour (Compassion, Attitude, Responsiveness and Excellence) that were inspired by our Roman Catholic heritage. 

This Policy applies to all employees, physicians, contractors, affiliates, volunteers, students, and learners who are engaged in SJHH business or working on SJHH premises, including affiliated sites.


2.0 Definitions

i. Affiliates include resident physicians, physicians who are not employees, and others affiliated with SJHH through a variety of ways, when engaged in SJHH business or working on SJHH premises.

ii. SJHH Business refers to all business activities undertaken in the course of SJHH’s operations whether conducted on or off SJHH premises.

iii. SJHH Premises includes but is not necessarily restricted to all land, facilities, affiliated sites, mobile equipment and vehicles owned, leased, rented or otherwise directly controlled by SJHH for the purpose of conducting SJHH business.

iv. Contractor refers to any person or entity, including their employees, that has been contracted, sub-contracted, or otherwise engaged to provide services to SJHH and is not on the payroll.

v. Learner refers to an individual who is registered either full-time or part-time in a recognized educational institution and who is pursuing a placement (clinical, academic or research-based) at SJHH.

vi. Volunteer refers to any unpaid individual assigned duties on SJHH premises.


3.0 Policy:

The standards of conduct that follow are not all-inclusive, but will serve as guidelines. Other relevant SJHH policies are referenced.

3.1 Behaviour with Patients, Visitors, Volunteers, Students, and Colleagues
We treat all patients, visitors, volunteers, students, and colleagues with kindness and respect. We understand that creating a stigma-free workplace and a safe, judgment-free environment for care is part of the expectations of our roles, and is a shared responsibility.

a. Dignity & Respect

  • We believe in the worth and dignity of the person and respect one another’s unique differences.
  • We treat each other in a manner that does not cause or perpetuate feelings of being stigmatized.
  • We lead by example to encourage our teams, our organization, our partners in caring, our circle of family and friends and the community to reject stigma.

Note: Stigma is a form of disrespect that results in unfavourable attitudes and negative behavior and ultimately to stereotyping, rejection and can lead to inequality in treatment.

b. C.A.R.E. Standards

  • We apply the C.A.R.E. Standards: Compassion, Attitude, Responsiveness and Excellence in our interactions with patients and each other.

c. Ethical Behaviour

  • We are accountable for conducting ourselves in a responsible manner and apply ethical behavior to all we do in accordance with the Hospital’s 039-HR Workplace Ethics Policy.

3.2 Competence and Productivity

a. Competent Performance

  • We perform the work as required by our position in a competent, careful and productive manner in compliance with acceptable standards of our profession, learner role and/or job description.

b. Cooperation

  • We work collaboratively with each other providing assistance to co-workers when needed and share relevant work knowledge and experience.

c. Notification if Under Investigation by Governing Body

  • We notify Human Resources/Chief of Department immediately if we are the subject of an investigation or inquiry by a registering/licensing/regulatory authority during the course of our relationship/employment with SJHH.

d. Hospital Training Programs

  • We attend SJHH training or lectures scheduled and paid for by SJHH during our working hours.

e. Mentoring

  • We participate as members of an academic and research health care organization by welcoming students, faculty and new staff acting as a mentor when assigned.

3.3 Attendance & Punctuality

a. Attendance

  • We report to work on time, stay until our shift ends, attend work regularly and follow the guidelines in 027-HR Attendance Management and our department specific guidelines.

b. Compliance with Breaks

  • We comply with unpaid meal breaks and rest periods scheduled by SJHH in accordance with 008-HR Hours of Work and Premium Pay, applicable Collective Agreements, and legislation and adhere to times that are established within our work area. We do not take unauthorized extra breaks to smoke.

c. Leaving Work Area

  • We do not leave our work area during work hours without permission of our Manager, apart from our unpaid meal break.

d. Absence Without Permission

  • We are not absent from work unless we have permission in accordance with SJHH policies and by-laws.

Note: If an employee is absent without permission for three working days, or overstays a permitted leave of absence, and fails in either case to furnish SJHH with justifiable reason for absence an employee’s services may be terminated.

e. Sleeping While on Duty

  • We do not sleep while on duty unless on an authorized break.

f. Personal Phone Calls

  • We make personal phone calls and read/send text messages during our breaks.
  • We do not use Personal Digital Assistant devices (PDA) while on duty unless for authorized work purposes. (Reference 119-ADM Use of Wireless Transmitting Devices)

Note: A manager may request to review an employee’s PDA to confirm it is being used for work related activities while on duty.

3.4 Orderly Conduct

We conduct ourselves in a professional manner.

Note: SJHH will not tolerate behavior that causes ridicule, contempt or humiliation of any individual or group of people.

a. Language & Conduct

  • We behave in an orderly manner appropriate to the workplace when dealing with patients, visitors, volunteers and colleagues. 
  • We do not engage in loud, abusive, threatening, intimidating or profane language. 
  • We do not engage in horseplay, scuffling, throwing things, assault or degrading treatment of others (Reference 100-ADM Prevention of Violence in the Workplace).

b. Harassment & Bullying

  • We respect the diversity of others and comply with SJHH’s 029-HR Harassment & Discrimination Policy.
  • We do not engage in acts of harassment (sexual or otherwise), discrimination, gossiping or bullying.

3.5 Providing a Safe and Secure Environment

a. Physical and Psychologically Safe Environment

  • We observe all health and safety regulations as well as meet the requirements of the Occupational Health and Safety Act for our own protection and that of our colleagues, patients and visitors. 
  • We follow complete instructions covering safe working methods and use safety equipment provided by SJHH
  • We report unsafe working environments to our Manager/Delegate immediately as per 006-OH&S Employee Incident/Hazard Reporting and Investigation.

b. ID Badge

  • We wear the photo identification badge issued by the Security Department at the time we commenced employment and if it is lost or damaged replace it as soon as possible.

Note: The identification badge includes our first and last name and is worn so it is clearly visible while on SJHH premises. The badge identifies our affiliation with the Hospital and minimizes opportunities for the intrusion of unauthorized persons.

c. Injury at Work

  • We promptly report any injury incurred on SJHH’s property to our Manager and to the Employee Health Service as per the Hospital’s 027-HR Attendance Awareness Policy and complete a Hazard Employee Incident Report as per 006-OH&S Employee Incident/Hazard Reporting and Investigation.

d. Scented Products

  • We respect the chemical sensitivities of our co-workers and patients by following the guidelines of SJHH’s 007-OH&S Scent Reduced Environment Policy.

3.6 Lawful and Honest Conduct

We behave in an honest and trustworthy manner, complying with the law and acting in a manner that does not undermine the employment relationship.

Note: Breaches may result in disciplinary action.

a. Theft

  • We do not take items belonging to SJHH or to patients, visitors or colleagues. If we witness a theft, we report the incident to our supervisor or security immediately following the incident.

b. Falsification of Records

  • We do not willfully falsify records including applications for employment, other data requested by SJHH, time sheets, or when signing in and out.

c. Conflict of Interest

  • We comply with SJHH’s 073-ADM Conflict of Interest Policy.

d. Weapons on Hospital Property

  • We do not bring any weapons onto SJHH property.

3.7 Confidentiality and Privacy

a. Confidentiality

  • We adhere to SJHH’s policy 090-ADM Privacy of Personal Information and do not access or disclose information that is not required in the normal performance of our duties.
  • We maintain confidentiality of all personal health information, medical records and other confidential SJHH information of patients, staff or SJHH.
  • We are aware of our environment when discussing confidential matters and act appropriately.

3.8 Patient/Client Boundaries

a. Relationships

  • We do not enter into personal, sexual or business relationships with patients/clients.

b. Borrowing

  • We do not borrow or lend money or property from/to patients/clients.

c. Gifts

  • We do not accept gifts from patients/clients and family members unless they are only of small intrinsic value i.e. candies that may be shared with colleagues.

3.9 Non-Impairment in the Workplace

a. Substance Misuse

  • We will not be on SJHH premises while under the influence of or consuming any alcohol, narcotic, controlled drug, or substance which causes impairment while on duty.
  • We will not engage in gambling during work hours.

Note: In accordance with SJHH Policy, any event serving alcohol must be approved by the President of St. Joseph's Healthcare Hamilton.

3.10 Care, Use and Maintenance of Hospital Property

SJHH reserves and intends to exercise the right to review, audit, intercept, access and disclose all messages created, received or sent over email for any purpose. The content of electronic mail, properly obtained for legitimate business purposes, may be disclosed within SJHH without the permission of the employee.

a. Use of SJHH Equipment (internet-access)

  • We do not damage or improperly use SJHH property, tools, machines or equipment.
  • We do not use SJHH equipment for personal use without permission of our supervisor.
  • We access the Internet from work for business purposes only (Reference 107-ADM Internet Security Policy)
  • We do not use SJHH assets to view or create material that is illegal or which a reasonable person might find offensive or disruptive such as those that contain sexual implications, racial slurs, gender specific comments or any other comment that offensively addresses someone’s age, sexual orientation, religious or political beliefs, national origin or disability.
  • We do not use SJHH property to send or reply to chain letters or distribute offensive or inappropriate materials; achieve personal gain, profit or advancement of personal views; to represent oneself as someone else; solicit other SJHH employees, solicit or proselytize for commercial ventures religious or political causes, outside organizations, or other non-job-related solicitations.

b. Smoking Area

  • We abide by SJHH’s 022-ADM Tobacco Free Policy and the Smoke Free Ontario Act if smoking.

c. Parking Privileges

  • We park on SJHH property in areas authorized.

NOTE: Violation of parking regulations, no parking signs and other traffic signs or non-designated parking areas may result in disciplinary action and/or the withdrawal of parking privileges (Reference 014-ADM Parking Policy).

3.11 Compliance with Supervision

a. Following Instructions

  • We follow our supervisor’s job-related instructions and do the work assigned.
  • If we feel that there is a problem, we carry out the instruction and discuss the issue with our supervisor later, unless the reason is believed to endanger our health and safety.

3.12 Professional Appearance

a. Dress Code

  • We follow the SJHH’s 030-HR Professional Image Standard (formerly Dress Code) Policy.


4.0 Procedure:

This section outlines how the actions will be performed and may include a decision-making framework. If none, state none.

5.1 Reporting Inappropriate Behaviour

  1. When dealing with rude or disrespectful behavior, we expect staff to address this directly with the individual involved if appropriate. The C.A.R.E. Standards of Behaviour gives guidelines on how to address this type of situation. If this does not resolve the issue or you are uncomfortable to approach the individual, contact your immediate supervisor for assistance. If you do not feel you are able to speak with your immediate supervisor, you may approach your manager’s supervisor or Human Resources.
  2. If you witness serious Policy infractions, you are responsible to report these to your Manager/Delegate immediately. The Hospital’s 038-HR Whistleblower Protection Policy provides an overview of the available process and associated protection from retribution.
  3. The Hospital will investigate policy infractions reported and take appropriate corrective action that could include discipline or a report to the individual’s legislative body.

5.0 References

5.1 Cross References

C.A.R.E Standards of Behaviour
011-HR Complaint Procedure for Non-Unionized Staff
026-HR Termination of Employment
027-HR Attendance Support Program
029-HR Harassment & Discrimination
030-HR Professional Image Standard (formerly Dress Code)
038-HR Whistleblower Protection Policy
039-HR Workplace Ethics Policy
014-ADM Parking
022-ADM Tobacco Free Policy
090-ADM Privacy of Personal Information
100-ADM Prevention of Violence in the Work place
107-ADM Internet Security Policy
119-ADM Use of Wireless Transmitting Devices
006-OH&S Employee Incident/Hazard Reporting and Investigation
007-OH&S Scent Reduced Environment

5.2 External References

Related Legislation
Ontario Human Rights Code (1990)
Occupational Health and Safety Act (1990)
Employment Standards Act
Smoke Free Ontario Act

6.0 Author(s)

VP People and Organizational Effectiveness

7.0 Sponsor

VP People and Organizational Effectiveness

8.0 In Consultation With

Director, Risk, Legal & Medical Affairs
Directors and Managers, Clinical and Non-Clinical

9.0 Posting Dates

Initial Posting Date: 11/05/2014
Posting Date History: 02/22/2019