Your champions for safe nursing care

In 2016, we strengthened our efforts in three areas: collaboration, decision-making and accountability.
Anne Coghlan, RN, MScN, Executive Director and CEO, College of Nurses of Ontario

It’s an incredibly challenging and exciting time to be the regulator of the nursing profession in Ontario. Our health care system is changing rapidly, and with it, the knowledge and skills nurses need in their evolving roles. You — the public we serve, and whose safety is the focus of our regulatory efforts — are more engaged than ever. Your input and feedback is enhancing our ability to perform our role.

The digital age has increased your expectation for quick, easy access to information. You want to know how you can participate in your care decisions and access reliable information to help you make those decisions. You want to know what safe nursing care looks like and you want a voice.

The College of Nurses of Ontario (CNO) is here for you. We’re working hard to anticipate change and ensure your safety is at the forefront of the standards we set and uphold. We’re working with the public, nurses and other stakeholders so that our regulatory processes are ready to support the changes needed for the ongoing delivery of safe nursing care.

To continue to improve public safety, in 2016 we strengthened our efforts in three areas: collaboration, decision-making and accountability. You’ll see examples of each of these throughout this report. You’ll also meet a few people who are champions for change: from nurses showing their dedication to ongoing education to members of the public who, by participating in our processes, are catalysts for improvement.

We encourage your involvement — together we will continue to prepare for the future of health care in Ontario.

Anne Coghlan, RN, MScN
Executive Director and CEO


Working together

For change to be meaningful and effective, it needs the active participation of those it affects. We’ve been working hard to improve the level of engagement we have with all who have a stake in nursing: the public, educators, students, employers and the government, as well as nurses, nursing organizations and other regulators across Canada and around the world.

Finding ways to get more feedback

Social media has been a big help in allowing us to share information instantly and quickly receive valuable feedback in return.

For example, when proposing changes to the number of times a nursing applicant can take the NCLEX-RN (an entry exam for applicants who want to become an RN), we used social media to seek input from everyone: from the public to nurses and their employers. The response was remarkable — the largest we ever had. Even though the consultation period was 30 days less than normal, we received feedback from 190 members of the public. We also heard from 1,022 nurses, 204 applicants, 83 educators, 83 other stakeholders (primarily nursing students), and 15 nursing employers. We’re looking to ramp up our use of social media and other platforms so we can continue to engage quickly and directly with our stakeholders.

For the first time, we also sought public feedback when developing a practice standard. Using surveys and focus groups, we consulted with the public about updating our practice standard for Nurse Practitioners (NPs). The results told us what you expect from NPs, and identified potential risks to public safety that NP practice represents.

Throughout this report, you’ll see other examples of how in 2016 we engaged and collaborated with individuals and groups on a variety of issues, including:

We were also involved in many other collaborations, including:

  • Academic Reference Group: Early in 2016, we met with representatives of every Ontario RN program to review each school’s results of the exam that RN applicants write — the NCLEX-RN. We discussed ways to ensure students have the information they need to prepare, register and take the exam. This outreach led us to form an Academic Reference Group. The group is made up of nurse educators of all education streams (Registered Nurses, Registered Practical Nurses and Nurse Practitioners), sizes of schools and geographic locations, as well as CNO staff. They discuss regulatory issues that may affect the education process, and we seek the group’s input to inform CNO’s regulatory work.
  • Transparency working group: The Ministry of Health and Long-Term Care invited CNO to participate in its Transparency working group. This group — which includes members of the public, Ministry representatives, employers and regulators — identified areas for greater transparency among health care stakeholders and public-facing documents on regulatory processes, such as the complaint process.
  • Opioid crisis: Opioid-related rates of addiction, overdoses and deaths are on the rise in Ontario and across the country. We are collaborating with other Canadian nursing regulators to develop a guidance document for Canadian regulators of RNs and NPs. The guide will help us take a standardized approach to nurses prescribing opioids, including: the education and practice needed to reduce harm; monitoring; and competencies nurses need when entering the profession that will help limit the potential for opioid abuse. We expect to have this document completed in 2017.
  • Psychotherapy: The Regulated Health Professions Act, 1991 (RHPA) is the governing legislation for regulated health professionals in Ontario. It identifies 14 “controlled acts” that may only be performed by authorized regulated health professionals, such as nurses. The controlled act of psychotherapy is a small aspect of the overall practice of psychotherapy. However, it is considered the part that is the highest risk to patients. It involves using a psychotherapy technique to treat a person’s serious thought, cognition, mood, emotional regulation, perception or memory disorder.

In 2016, CNO collaborated with regulators whose members are authorized to perform the controlled act: College of Occupational Therapists of Ontario, College of Psychologists of Ontario, College of Registered Psychotherapists of Ontario, and Ontario College of Social Workers and Social Service Workers. This effort resulted in a new document: Understanding When Psychotherapy is a Controlled Act. At the end of 2016, we sent this document out for feedback. By early 2017, we received 2,670 responses. We used this feedback to provide more clarity in the document. As of June 6, 2017, the controlled act of psychotherapy had not yet been proclaimed by the government, and we are awaiting further information from the Ministry.


Making the best decisions

Out of collaboration comes better decision-making. To ensure public safety, our decisions need to be informed by evidence. By seeking out information, we can proactively influence change, rather than react to it after it has occurred. For example, we’ve been proactive in looking at how CNO is governed. As a result of an extensive evidence-based process, in 2016 CNO’s Council adopted a governance vision for 2020.

Standards and regulations are other areas where we use evidence to make good decisions about needed changes. For example, in 2016 our regulations changed so now there is no limit on the number of times RN applicants can attempt the NCLEX-RN registration exam. When we initially implemented the exam in 2015, writers had three attempts to pass it.

Canada’s regulators monitored the exam’s outcome, and evaluated the exam using Canadian evidence. In November 2015, a national working group began examining evidence related to the number of attempts on the RN entry exam in Canada, and computer-adaptive exams in general. The analysis shows that the exam’s content, format and security features mean that writers can’t pass the exam unless they have the abilities needed. For example, to pass, they must know how to: assess and respond to changes in vital signs; perform comprehensive health assessments; assess a client’s need for pain management; perform calculations needed to safely administer medications; and, maintain client confidentiality and privacy.


Becoming more accountable

The government expects regulatory bodies to increase the transparency of our information. CNO has been proactive in expanding information about nurses’ conduct, which we share on the public Register Find a Nurse.

It’s a great start, but we still have more work to do in the public’s interest to be as transparent as possible about how and what we’re doing. For example, when investigating a concern about a nurse, we comply with the law by keeping information confidential; we can only confirm we’re investigating. As times change and the demand for transparency strengthens, laws, regulations and standards need to keep pace.

We shared with the government our thoughts about possible legislative changes that could enable us to share with the public relevant information about our investigations. We know that sharing more information about our processes and actions increases your confidence that we are working to protect your safety.

In addition to the work we’re doing with the government and other regulators, we continue to make enhancements in two areas:

Clear Language: This ongoing initiative improves the clarity of CNO’s written communication so that all of our stakeholders find what they need, understand it and use it to fulfil their needs. It helps us to maintain transparency and accountability.

Business transformation: In 2016, we continued work with the College of Registered Nurses of British Columbia’s consortium to make use of their regulator-designed technology solution. This multi-year, multi-phased initiative involves making improvements to our work processes and technology to help us deliver exceptional customer service. To make them more efficient, we’re redesigning some of our business processes used by those applying to CNO or renewing their membership. The new system will also provide us with additional data that we can use to make more informed decisions and reduce the time to investigate a public complaint about a nurse.