Practice - A resource for nurses and nurse leaders
  September 2018 | Volume 17, issue 2
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Sexual abuse act steps up patient protection

Changes in legislation came into effect in May 2018 which may affect nurses’ practice and reporting requirements. The changes strengthen measures to protect patients; support victims of sexual abuse by regulated health professionals; and improve regulatory oversight and accountability.
These changes are part of the Protecting Patients Act, 2017, and they amend the Regulated Health Professions Act, 1991 (RHPA).
The changes include:

  • New definition of “patient”
    Within the context of sexual abuse, an individual is now considered to be a “patient” for one year after the therapeutic nurse-client relationship ends. This means that any sexual contact between a nurse and patient (or former patient) within the one-year time frame is sexual abuse. It does not matter if the patient consents to the sexual acts.
  • Funding eligibility for therapy and counselling for victims of sexual abuse
    Patients can now immediately apply for funding for therapy and counselling as soon as they file a complaint of sexual abuse.
  • Expanded list of sexual abuse acts and other conduct resulting in mandatory revocation
    Due to the amendments the Act makes to the RHPA, there are now more sexual acts that result in mandatory revocation of a nurse’s certificate of registration.
  • More information on the public Register (Find a Nurse)
    Nurses will be required to report all licences or registrations they have for all other professions in any province or country. This means if a nurse is a member of another body that governs a profession inside or outside Ontario, they must inform the College.

    For example, if a nurse is an accountant and is registered with a regulatory body in the United Kingdom, they must report this to the College.
    Previously, nurses only reported other nursing registrations to the College.

    Nurses can report other professional licences or registrations by logging on to Maintain Your Membership.

The College exists to uphold safe nursing care for the public. We are committed to ending sexual abuse. Learn more about the Protecting Patients Act, 2017 on the Ontario Government website .

What happens when a nurse is suspected of sexual abuse of a patient? Find out at: www.cno.org/sexual-abuse.

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Changes to NP practice

Recently, three significant changes to NP scope of practice came into effect. First, NPs can now order ultrasounds and X-rays without restrictions. They can also prescribe diacetylmorphine (heroin) and methadone. Lastly, NPs have a new reporting requirement. The College is providing regulatory oversight for these changes to protect the public’s right to safe nursing care.

Ordering ultrasounds and X-rays

As of April 1, 2018, NPs have the authority to order ultrasounds and X-rays without restrictions. This change does not include computerized tomography (CT) scans.

Previously, NPs could only order ultrasounds and X-rays based on lists under the Regulated Health Professions Act, 1991, and the Healing Arts Radiation Protection Act, 1990, respectively. The new authority eliminates these lists.

When ordering tests, NPs are accountable to the expectations in the College’s practice standards, including Decisions About Procedures and Authority and Nurse Practitioner.

NPs are expected to have the knowledge, skill and judgment to order appropriate tests, and to communicate clinically significant results and their implications to clients.

For more information about these changes, visit: www.cno.org/nps-ultrasound-xray.

Prescribing diacetylmorphine and methadone

As of May 19, 2018, NPs are authorized to prescribe diacetylmorphine (heroin) and methadone. This new authorization results from changes under the Controlled Drugs and Substances Act.

Previously, NPs were only authorized to prescribe or administer methadone if they had an exemption under section 56 of the Act. Now that the government has changed the Act, NPs can prescribe and administer methadone without an exemption. Also, diacetylmorphine is included on the list of controlled substances that NPs can prescribe.

These changes are part of government’s response to the national opioid crisis. The liberal use of opioids for treating chronic non-cancer pain has contributed to opioid addiction in North America. The government is making efforts to increase health care access for Canadians who need treatment for substance use disorder.

Nurses can learn more about the risks associated with these controlled substances, as well as their accountabilities when prescribing medication (including diacetylmorphine and methadone) at: www.cno.org/np and in our FAQs.

NPs must now report medically unfit drivers

As a result of recent changes to the Highway Traffic Act, 1990, NPs have a new reporting requirement. NPs are now required to report to the Ministry of Transportation specific high-risk medical conditions, functional impairments and visual impairments in clients 16 years of age or older.

A list of the conditions that NPs must report can be found in Ontario Regulation 340/94, section 14.1 (3) . Additionally, NPs can also report clients if they have or may have a condition that, in the NP’s opinion, makes it dangerous for them to drive.

NPs can submit a report and learn more about this new reporting requirement at the Ontario Ministry of Transportation website.

Get the score on nursing exams

Curious about how many applicants to the College passed their registration exam in 2017? Find answers in our new report about nursing exams.

The report shows the pass rates for applicants who wrote one of the College-approved national registration exams, as part of the registration process for becoming a nurse in Ontario. The exams for RNs (NCLEX-RN) and RPNs (CPNRE) test competencies that nurses need to begin their nursing careers in Ontario. They help ensure that new nurses in Ontario are prepared to practise nursing safely.

In 2017, approximately 12,000 applicants to the College wrote either the NCLEX-RN or CPNRE at least once. Of all RN applicants who wrote the NCLEX-RN, 76 per cent passed on their first attempt. The pass rate for applicants educated in Ontario was 80 per cent. Of the RPN applicants who wrote the CPNRE, 86 per cent passed on their first attempt. The pass rate for applicants educated in Ontario was 92 per cent.

You can find more information about the pass rates for these and other exams, as well as a breakdown of pass rates by Ontario nursing education program, and of applicants educated elsewhere in Canada and internationally, in our Nursing Registration Exams Report.

The College publishes annual statistics reports to provide data about the nurses we register. Find out more about our statistical resources and sign up for announcements at: www.cno.org/stats.

Fee changes now in place

After reviewing feedback about proposed fee changes, which we announced in the March issue of The Standard, Council approved the changes at its June 2018 meeting. The new fees will help ensure the College can continue to meet its mandate to protect the public and the reputation of the profession, and ensure the public trusts nurses.

Between March and June, we collected feedback from nurses, applicants and other stakeholders on proposed changes to four of the College's fees for: renewing annual membership; applying to the College; taking the PN exam; and cancelling the PN exam.

Using nurses’ feedback

In April, we provided answers to the most common questions nurses had about the fee changes. Many wanted to know what membership fees pay for, why all nurses in Ontario pay the same membership fee, and why the fee doesn’t include professional liability protection. We answer these questions and more at www.cno.org/faq-fees.

We gave Council members a full report of all the feedback sent to us. This included an analysis of common themes that emerged from stakeholders’ comments. Council had the opportunity to carefully review all feedback before making a decision.

Ultimately, Council decided that fee increases are necessary to effectively fulfil our accountabilities to the public, to ensure the College can maintain a sound financial position and meet our growing needs.

Read about how we consulted with nurses, applicants and others, as well as a summary of the feedback we received, on pages 131 – 133 of the June Council meeting materials.

Here are the newly approved fees:

Name of fee


Effective date

Annual membership fee


2019 membership renewal 

Application fee



Practical Nurse exam fee


June 2019


June 2020

Cancellation fee for Practical Nurse exam



What did we do in 2017? Read our Annual Report

Our 2017 Annual Report is out, and it’s a little different from previous years.

Titled “Leading in Change,” the report is shorter and more visual than ever before. In addition to the articles, the report features infographics to help tell the College’s stories. To create them, we drew from the wealth of data and evidence-based information that the College collects.

As well, to help people understand our mandate of public protection, we speak directly to members of the public.

These changes make it easier for everyone to understand the work the College did in 2017. Here are just some of the ways we worked to advance public protection in Ontario by influencing health care regulation:

  • making sure RN prescribing is safe
  • protecting patients from sexual abuse
  • ensuring NPs have the education needed to prescribe controlled substances
  • changing the way we deliver practice support services to nurses
  • piloting a new process for ensuring graduates are ready to practise safely.

What percentage of the public say they trust nurses? Which College resources did nurses request the most in 2017? Where do most RPNs work? Find the answers to these and other questions in our 2017 Annual Report. Also look for it on LinkedIn and Facebook.

Ensuring client safety: Assessment and care transitions

The College is seeing an increase in the number of nurses who are not performing ongoing client assessments at the frequency needed to ensure client safety. This pattern emerges when we review cases in which clients are exposed to risk.

Ongoing client assessments are critical to providing safe client care. Assessment is a professional accountability and an essential part of nursing practice, as outlined in Professional Standards, Revised 2002.

All nurses are expected to regularly assess clients. However, certain clients may require more frequent assessment. For example, if a nurse works with clients who have acute mental illnesses, frequent checks are essential because there are unique safety issues for these clients, which may include an increased risk of violence, self-harm and suicide. Some of these clients may be isolated, require restraints or have a limited capacity to advocate for themselves. Frequent monitoring supports client safety. Clients who are classified as being high risk may require monitoring as frequently as every 15 minutes.

Communication is key

Another source of risk to clients is the potential loss or miscommunication of client information during the transfer of care or handover. Care transitions happen often, such as when a client experiences a change in health care providers or location, when a shift ends or a nurse takes a break. Each time, the nurse must communicate client-specific information to a colleague that is clear, focused and comprehensive.
Nurses should work with their health care team to establish and maintain effective communication. Nurses should consider:

  • What are the potential risks to my clients?
  • How can I clearly and effectively communicate client information between health care providers in our practice setting?
  • Is this communication sufficient to minimize risk for my clients?
  • Is this communication sufficient to facilitate the continuity of care?
  • How does our current practice contrast with best practice evidence?

Using effective communication strategies to meet the therapeutic needs of a client is one  accountability as outlined in Therapeutic Nurse-Client Relationship, Revised 2006. This also applies during care transitions.

Shared accountability

The Professional Standards practice standard states that nurses must facilitate, advocate and promote the best possible care for clients. They must also take action if client safety and well-being are compromised. Therefore, if a nurse has concerns about their ability to perform ongoing assessments appropriate for their practice, they should speak to their clinical manager and ask their team for support.

Nurses in administrative roles should work with their team to develop policies for a safe work environment in the best interest of clients and professional practice. All members of the health care team have a shared accountability to advocate for a quality practice environment that supports nurses’ ability to provide safe and effective care.

Understand the standards

Practice standards outline the expectations for nurses that contribute to client safety. Practice guidelines, which often address specific practice-related issues, help nurses understand their responsibilities and how to make safe and ethical decisions in their practice.

Would you like to better understand the standards and how to apply them to your practice? We can help! Check out our tools and resources page, as well as Ask Practice, which answers your most frequently asked practice questions. You can also contact our Practice Support team with any practice question by filling out our Practice Support form.

New practice exam for NCLEX-RN

Baccalaureate nursing students who would like to get a feel for what it means to take the RN nursing exam can now purchase a practice exam to help themselves get ready.

The practice exam follows the format of the online NCLEX-RN exam. It includes past exam questions, and is available in both English and French.

Just like the NCLEX-RN, the exam is timed. Also, the applicant has to answer each question before proceeding to the next one, and will not be able to go back to previous questions.

By knowing what to expect of the exam-writing experience, applicants will be better prepared for the exam. The practice exam will familiarize them with the NCLEX-RN’s content and structure, so they know how to navigate it.

While the practice exam can help applicants prepare for the NCLEX-RN, it does not predict the applicant’s success on the actual exam.
The NCLEX-RN practice exam is available for purchase for $150 USD. Visit www.nclex.com for more information.

Sonographers now regulated in Ontario

Diagnostic medical sonographers are now regulated by the College of Medical Radiation Technologists of Ontario (CMRTO).

Nurses who are currently registered with CNO do not have to register with CMRTO. RNs and RPNs already have the authority to perform diagnostic ultrasound procedures provided that the procedure is part of a routine nursing assessment and the member has a therapeutic nurse-client relationship.

Unregulated individuals who practise medical sonography should visit www.cmrto.org to register with CMRTO.

Coming soon: Online application process

Individuals wanting to become a nurse will soon be able to apply online. Starting in late September 2018, a new online portal will replace most of our paper application process.

The new portal, available in English and French, is part of an upgrade to our computer systems that allows us to offer more efficient service, including self-service options.

Once the portal becomes available, applicants will be able to do the following transactions:

  • set up an account and submit their applications
  • update their personal information (such as address and email)
  • pay fees and receive receipts 
  • schedule exams
  • upload documents when completing an initial application
  • receive updates about an application via a message centre.

Find out more about the new application process.

New requirements for dispensing opioids

New requirements are coming into effect for dispensing Class A opioids (a drug listed in Part A of the List of Opioids).

Beginning on Tuesday, Oct. 23, 2018, nurses are required to apply a warning sticker to the prescription bottle, container or package used when dispensing. They also need to provide the client with a patient information handout.

Nurses who administer prescriptions directly to clients do not need the sticker or handout. If you have questions about the difference between dispensing and administering, see the Medication practice standard and read our FAQs about dispensing opioids and labels.

Nurses will be responsible for obtaining and producing copies of the sticker and handout to use in their own practice. Both are available on the Government of Canada’s Website.

This requirement results from new laws under the Food and Drug Regulations. It affects all health care professionals who dispense Class A opioids. For more information, read Health Canada's Q&As about prescription opioids.

Is it a medical directive or prescribing?

The College continues to work toward changes that will, in the future, permit some Ontario RNs to prescribe certain medications. However, our consultations with nurses and other stakeholders reveal many people confuse prescribing with medical directives, which are different. All nurses, whether using medical directives or prescribing, need to be clear on where their authority comes from and what their accountabilities are.


During our consultations, some nurses said they are “already prescribing” via medical directives. This is not accurate. To prescribe means to provide a prescription; it is an order, authorization or instruction to provide or perform a procedure, treatment, medication or intervention. 

The professional prescribing a medication must have legal authority to do so and is accountable for the prescription. This includes determining the treatment is appropriate and warranted for the client’s condition.

Medical directives

Medical directives allow nurses to implement a procedure, treatment, medication or intervention for any clients meeting specific conditions and within specific circumstances. 

A medical directive for medication is authorized by a health professional having the authority to prescribe the medication, such as a physician or NP. The health professional who authorizes the medical directive is ultimately accountable for it. Nurses using the directive are not prescribing that medication. Rather, they are implementing a prescription from another health professional.

Nurses using medical directives are accountable for implementing them safely. This includes assessing your client to ensure conditions and circumstances outlined in the directive are met. If they have any questions about whether the directive is suitable for a client, the nurse is expected to consult with the authorizing physician or NP. For more information, see the Medication practice standard, and the Authorizing Mechanisms and Directives practice guidelines.

Preparing for RN prescribing

We expect RN prescribing to happen in many community, long-term care and retirement home practice settings, where medical directives are commonly used. Therefore, nurses and employers must be aware of the differences between medical directives and prescribing, and use increased diligence to ensure accountabilities are clear. 

For instance, a prescribing RN may provide a medication to a client, and a non-prescribing nurse may be able to provide that same medication to another client using a medical directive. Although the outcome for the client may be the same, it is important for nurses and employers to understand that the prescribing RN and the non-prescribing nurse have different accountabilities when providing the same medication.

Additionally, prescribing RNs might still use directives themselves. For example, they may use directives for medications that they are not authorized to prescribe.

Follow our journey to RN prescribing.

College wins regulatory award

On August 16, 2018, the College received the Regulatory Achievement Award from the National Council of State Boards of Nursing (NCSBN). The award recognizes an NCSBN member board or associate member that made an identifiable and significant contribution to NCSBN’s mission and vision, promoting the public’s interest through public policy related to safe and effective nursing practice.    

The award recognizes the College’s many contributions and leadership in regulatory excellence including Council’s bold vision for sweeping changes to our governance model. They also include our:

  • new evidence-informed process for approving nursing education programs
  • work co-founding Ontario’s innovative Advisory Group for Regulatory Excellence, which worked with other Ontario health regulators to enhance transparency through public access to information
  • collaboration with national and international regulatory colleagues promoting common approaches to public protection
  • work with the College of Registered Nurses of British Columbia and NCSBN, to develop a database that will allow the two regulators to share licensing information securely across borders.  

“Over the last several years, the College has focused on increasing the transparency of our work and building on and leveraging available evidence to support our decision-making,” says Anne Coghlan, Executive Director and CEO. “Our work has been enhanced through active collaboration with the public and other regulators in Ontario, across Canada and around the world.”

NCSBN, an independent, not-for-profit organization, has evolved into a leading voice of regulation around the world. Its mission is to provide education, service and research through collaborative leadership to promote evidence-based regulatory excellence for patient and public safety. The organization’s membership comprises boards of nursing, nurse regulators and empowered regulatory authorities from across the U.S., Canada and around the globe.

“Our vision is leading in regulatory excellence,” says Coghlan. “Sharing innovations with others and working collaboratively moves us closer to that excellence for which we strive. It’s exciting to see our work recognized by NCSBN.”

Read NCSBN’s article about the award in the summer 2018 issue of their publication, In Focus.  

Professional Standards updated

We have updated the Professional Standards, Revised 2002 practice standard. Now, it includes specific examples of legislation that requires nurses to report instances of abuse in their practice.

Professional Standards states that each nurse is accountable to the public and is responsible for ensuring their practice and conduct meet legislative requirements and the standards of the profession.

One way nurses demonstrate this accountability is by reporting to the appropriate authority any health care team member or colleague whose actions or behaviours toward clients are unsafe, unprofessional or indicate abuse.

Page 4 of the updated practice standard includes the names of some of the legislation that applies to the reporting accountability (in addition to the Regulated Health Professionals Act, 1991). These are:   

  • Long-Term Care Homes Act, 2007
  • Child Youth and Family Services Act, 2017 
  • Public Hospitals Act.

For clarity, we have also added a definition of “abuse” in the footnotes.
Read more about your accountability for reporting abuse.