Quality Practice - A resource for nurses and nurse leaders
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New Reporting Form easier to use

As part of CNO’s ongoing strategy to enhance our Professional Conduct procedures, we have updated the reporting form that is used when making a report about a nurse’s conduct or capacity. The form can be used to report any information to CNO, not just incidents that employers are required to report.

The updated Reporting Form, formerly called the Report Form for Facility Operators and Employers, has new features to make it easier for someone to complete and submit it. We have addressed some gaps to make the process more efficient and effective to help protect the public.

First, instructions have been added to the form. This allows the user to understand the process without having to go back and forth between the form and the instructions on www.cno.org/reports.

Second, we have added clarity to a section on employers’ reporting responsibilities and requirements. We have added an option for “Non-mandatory reports.” This is for information that isn’t required under regulation to report, yet the employer feels it is in the public’s best interest to make CNO aware of the incident.

We also made it clear that, under the Regulated Health Professionals Act, employers are required to report when a nurse is revoked, suspended or restrictions are imposed on their practice because of professional misconduct, incompetence or incapacity. Previously, we only listed their requirement to report when the nurse is terminated, or, if the nurse resigns instead of being terminated, for the same reasons.

Third, we have added more sections to the form for describing the incidents that led to the report. We want to ensure that users are aware there is no limit to the amount of information they can provide.

This Reporting Form will eventually be replaced with an online, interactive reporting form. We will begin planning the form by the end of 2018, and begin development in 2019.

We will continue to share information on www.cno.org and in future issues of Quality Practice to help you understand what, when and how to inform CNO of any concerns related to nursing practice.

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CNO and nurse employers working together for public safety

As employers, you play a critical role in public safety by supporting the regulatory functions of the College. One essential way you do this is by participating in our reporting process and monitoring programs.

To enhance collaboration and provide more opportunities for education, discussion and consultation, the College has created an Employer Reference Group.

The main objectives of this group is to:

    • Discuss and collaborate on regulatory topics of mutual interest
    • Clarify respective roles in public protection
    • Identify areas to support employers’ needs relating to nursing regulation, such as policies, standards and guidelines, mandatory reporting and professional conduct processes
    • Propose recommendations related to regulatory work

The group is composed of two sub-groups: one representing the long-term care sector and one for multi-sector areas. Both sub-groups are comprised of nurse employers from across the province who have volunteered to participate. They will bring a diverse range of nursing experience and knowledge to discussions that will enhance nursing regulation in the public interest.

The group will meet quarterly to focus on emerging priorities. Visit our Employer Reference Group page to learn more about the group, review the terms of reference and access meeting minutes.

Clarifying nursing conduct for the public

In the ever-evolving world of health care, it’s essential that the public continues to trust and have confidence in the care that nurses provide.

That’s why we’ve begun work on a code of conduct for nurses. The code will clearly explain to the public what they can expect from nurses when receiving health care. By upholding the standards of the code, all nurses will demonstrate a commitment to ensuring safe nursing practice.

The accountabilities in the code will not be new or different from current expectations for nurses. The accountabilities will reflect the fundamental values and principles at the core of nursing. For instance, that nurses maintain patients’ trust by providing safe and competent care.

While the College’s current practice standards provide more detailed guidance for nursing practice, the code will act as an overarching standard. It will outline the expectations of professional behaviour for all nurses, regardless of their role, job description or practice setting.

This fall, we shared a draft of the code for consultation with nurses, the public, educators, nursing associations, nursing unions and government. The code will go to Council for approval next month.

Cannabis is legal. Now what?

On Oct. 17, 2018, the Government of Canada legalized the recreational use of cannabis. While the legality of this drug has changed, nurses’ accountabilities to provide safe care have not.

As self-regulating professionals, nurses are required to ensure their practice and conduct meet the requirements of the profession and protect the public.

Mood-altering substances such as cannabis can impair your ability to think clearly, make sound judgments and act decisively. This puts patients at risk and jeopardizes patient safety. Under the Regulated Health Professions Act, 1991, working while impaired by any substance is considered to be professional misconduct.

It is important to note that cannabis affects everyone differently. Nurses must use professional judgment to determine whether using cannabis recreationally might interfere with their ability to provide safe care. If a nurse thinks they may be impaired or affected by any substance (for example, opiates, alcohol or cannabis) or even illness, they must not provide nursing care. This accountability is outlined in the Professional Conduct reference guide. Failing to meet this expectation may result in an investigation by the College.

Nurses also have a responsibility to report to their employer when they believe another nurse or health care provider may be impaired. This accountability is outlined in the Professional Standards, Revised 2002Ethics and Therapeutic Nurse-Patient Relationship, Revised 2006 practice standards.

Annual Membership Renewal open now

Annual Membership Renewal is open. The deadline for nurses to renew their membership is Monday, Dec. 31, 2018. Nurses must renew their membership with the College each year to continue practising as a nurse in Ontario.

The process is quick, easy and secure. Nurses can log on to Maintain My Membership with their email and password, and follow the prompts. It should take no longer than 10 minutes to complete.

Nurses should also remember to update their employment information if it’s changed. CNO’s by-laws require nurses to report any change in their employment information to us within 30 days. It is their responsibility to update this information any time their employment changes, not just during renewal.

Here’s what’s new for the 2019 renewal:

New membership fee
The fee for members in the General and Extended Classes has increased to $270. Council approved this increase at its June meeting. The new fee will help ensure the College can continue to meet its mandate to protect the public as well as to protect the reputation of the profession, and to help ensure the public trusts nurses. Read the fee increase FAQs to find out why these changes were made.

Important dates 

Deadline to pay without late fees 
Monday, Dec. 31, 2018

Notice of intent to suspend letter mailed to members with incomplete renewals 
Monday, Jan. 14, 2019

Suspension for members who have not completed renewal 
Wednesday, Feb. 20, 2019

Expiration of memberships for members who have not completed renewal 
Friday, March 22, 2019 

New reporting requirements: Adverse events for vaccines and contagious diseases

As a result of recent amendments to the Health Protection and Promotion Act, nurses have new reporting requirements to make to their local Medical Officer of Health. These are for adverse events following immunizations and reporting diseases of public health significance.

Reporting adverse events after immunizations
If a nurse provides immunizations to patients, they are now required to report to their local Medical Officer of Health any adverse events following immunizations for all authorized vaccines in Canada.

An adverse event is any event or reaction that occurs after receiving a vaccine. The report should contain:

  • The name and address of the facility where they treated the patient for their adverse event
  • The date they treated the patient
  • The nurse’s name and address
  • A list of all vaccines the patient received before (and potentially associated with) the adverse event

The report may require additional information for certain vaccines. For more information about what goes in the report, as well as an updated list of authorized vaccines, nurses can read Ontario Regulation 569 or contact their local public health unit.

Reporting diseases of public health significance
The Ministry of Health and Long-Term Care maintains lists of the highly contagious diseases that pose a significant risk to public health. If a nurse suspects or has confirmation that a patient has one of these diseases, they must report it to their local Medical Officer of Health.
To reflect current public health priorities, the lists of designated diseases on the “Ontario Reportable Disease List,” have been updated and combined into one new list. The new list is called “Diseases of Public Health Significance.”

Diseases that have been added to the list and must be reported:

  • Colonization or infection of Carbapenemase-producing Enterobacteriaceae (CPE)
  • Blastomycosis (also known as Gilchrist's Disease or North American Blastomycosis)
  • Echinococcus multilocularis infection

Changes to the list:

  • The requirement to report invasive Haemophilus influenza b disease has been expanded to include all types of Haemophilus influenza. Previously, only type b had to be reported
  • The requirement to report respiratory infection and gastroenteritis outbreaks in institutions has been expanded to include outbreaks in public hospitals

Diseases that have been removed from the list and no longer need to be reported:

  • Yellow fever
  • Malaria

The complete and updated list of diseases of public health significance that must be reported can be found at Ontario Regulation 135/18.

If nurses have questions about these reporting requirements, they should contact their local public health unit.

New requirements for dispensing opioids now in effect

Nurses who dispense Class A opioids (drugs listed in Part A of the List of Opioids), should know that new requirements are now in effect.

As of Oct. 20, 2018, nurses who dispense any of these medications are required to apply a warning sticker to the prescription bottle, container or package. They also need to provide the patient with a patient information handout. Nurses are 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.

If a nurse administers the medication directly to the patient, rather than dispense it, the sticker or handout is not necessary. If nurses have any questions about the difference between dispensing and administering, they should refer to the Medication practice standard and read our FAQs about dispensing opioids and labels.

This new requirement is a result of government efforts to increase patient access to clear information about the safe use of opioids. This change comes from new laws under the Food and Drug Regulations and affects all health care professionals who dispense Class A opioids. For more information, read Health Canada's Q&As about prescription opioids.

Why do nurses need a Learning Plan?

Why does our Quality Assurance (QA) Program emphasize self-reflection? Because the evidence tells us that the ability to reflect is an essential skill for nurses.

Reflection helps nurses grow and learn - and the ability to continually grow and learn is crucial to maintaining the ability to provide safe nursing care. That's why continuous improvement is a nursing accountability. It's also why we have designed every element of our QA Program to support nurses’ ability to reflect and learn.

QA is more than just CNO assessing nurses’ ability to reflect. When a nurse participates in QA by creating a Learning Plan - an action plan for how to address the areas for improvement they have identified - they demonstrate to the public that they are dedicated to making their practice the best it can be. It's also a way for us to support nurses and help them improve their practice. Next month, when nurses begin creating their Learning Plans, they should take advantage of the resources we’ve created to assist them. Our learning modules, worksheets and webcasts can help nurses develop measurable and SMART learning goals.

We know our QA Program works. When a nurse is selected for the Practice Assessment portion of QA, we evaluate their ability to reflect and their knowledge of CNO standards. Over the last five years, of the nurses who were not able to demonstrate an ability to reflect or a knowledge of the practice standards, 88% were successfully able to improve and learn through remediation. Supporting nurses this way is one of the key ways we protect the public.

We've replaced the Am I Practising Nursing? fact sheet

First published in 1997, the Am I Practising Nursing? fact sheet was developed to help nurses and applicants decide if their nursing experience was considered “nursing practice.” This must be determined when renewing their membership or registering with CNO, and to determine participation in Quality Assurance.  

To help nurses understand if their experience is considered nursing practice, we have replaced the fact sheet with clear and updated information on Become a Nurse and in Maintain Your Membership. This includes reflective questions and a definition of nursing practice. We have also posted FAQs in the Declaration of Practice section in Ask Practice.

There, you can find information about what can and can’t be used as declaration or evidence of practice, such as caring for a family member or friend.

When nurses renew their 2019 membership, they should review the reflective questions and decide if their practice qualifies as “nursing practice.” If it does, they should register in a practising class. If it doesn’t, they can choose the Non-Practising Class or resign their membership.

NPs must report requests for MAID

NPs who offer medical assistance in dying (MAID) to patients have new reporting requirements. Within 30 days of receiving a written request for MAID from a patient, NPs are now required to report directly to Health Canada, via the new Canadian MAID Data Collection Portal, if any of the following occur:

  • they refer or transfer the patient to another practitioner or care coordination service
  • they find the patient to be ineligible for MAID
  • they become aware that the patient has withdrawn their request for MAID
  • they become aware that the patient has died from a cause other than MAID

If an NP provides MAID to a patient, by either administering a substance, or prescribing or providing a substance for self-administration, their reporting requirements have not changed. NPs must still report deaths from MAID to the Office of the Chief Coroner for Ontario (OCC).

The new reporting requirements, which came into effect on Nov. 1, 2018, are a result of government efforts to collect more information about requests for and access to MAID in Canada.

Additionally, the OCC is taking a more active role in overseeing and monitoring reports of MAID deaths in Ontario. This is to ensure accurate and consistent reporting across the province. If a nurse submits a report to the OCC, the OCC may follow up directly if any part of the report is unclear or incomplete. Read more about the OCC’s oversight process in this letter from the Chief Coroner of Ontario.

For more detailed information about the new federal reporting requirements, read the reporting FAQs and Health Canada’s Guidance for reporting on medical assistance in dying.

If nurses have questions about their professional accountabilities when providing medical assistance in dying, they should visit our Medical Assistance in Dying page or read Guidance on Nurses’ Roles in Medical Assistance in Dying.

Be a voice for patients

CNO is looking for nurses who understand patient safety and have experience advocating for patients’ rights to volunteer for one of our committees. The application period is open now and closes on Tuesday, Dec. 4, 2018.

In 2019, we will need NPs, RNs and RPNs to join our Discipline and Inquiries, Complaints and Reports Committees. As well, we will need NPs and RNs to sit on our Fitness to Practise and Quality Assurance Committees.

Nurses who are interested in volunteering can go to our Committee page first to find out the work these committees do, as well as the skills and attributes we’re looking for in candidates.

We’ve created an educational video to explain committee work and help nurses decide if their unique knowledge, skills and experience are right for the job. Those who think they might be a fit can begin the application process.

Visit our Committee page to learn more.