The following scenarios are designed to provide guidance around circumstances in which employers are required to make a report to the College.
Reporting incapacity: scenario #1
Brenda, a nurse on an ICU, is suspected by her manager of having a drug abuse problem and of diverting medication from the unit for her own use. Brenda frequently asks co-workers to co-sign for wastage they have not witnessed. Her clients are treated with higher dosages of PRN pain medication than other nurses’ clients on the unit. She primarily works night shifts, takes lengthy breaks and has taken above-average sick time. Her manager has noticed that Brenda is loud and boisterous one moment, and withdrawn the next. In addition, Brenda’s partner has expressed concerns to the manager about Brenda’s health. When asked, Brenda denied that she has any health issues. Does the facility operator have an obligation to report the manager’s concerns to the College?
It is mandatory for a facility operator to report to the College when there are reasonable grounds to believe that a nurse is incapacitated. "Incapacitated" means that the member has a physical or mental condition, and the disorder affects the member’s ability to practise safely. In the preceding scenario, there are several indications that Brenda may have a health condition affecting her practice. The facility should determine if these indicators suggest that Brenda meets both requirements of the definition of incapacitated: (1) that she has a condition or disorder and (2) that her practice warrants some restrictions. Brenda does not need to admit that she is incapacitated. Nor does the facility operator have to “prove” the concerns are true before the obligation to report arises. After the report is filed, the College will assess the information and determine the appropriate regulatory action. If further inquiries regarding Brenda’s health are appropriate, the information will be reviewed by the Inquiries, Complaints and Reports Committee (ICRC).
Reporting incapacity: scenario #2
Paul, a nurse at a retirement facility, is being treated for bipolar disorder. The owner of the facility has never had any concerns with Paul’s practice, conduct, or his relationships with his nursing colleagues or clients. Paul has had some short-term absences, which were supported by his physician, but he has always returned to work in good health. However, the facility operator wonders if he is required to report Paul’s condition even though there have been no practice issues.
There are two components to the definition of incapacity in the Regulated Health Professional Act, 1991:
- the member must have a physical or mental condition; and
- the condition must warrant restrictions (or a prohibition) on the member’s practice.
In this case, Paul’s health condition has not affected his nursing practice. Paul also removes himself from practice when necessary; therefore, the facility likely has no reason to believe that he is incapacitated as defined in the legislation and the College would not expect a report.
Reporting incompetence: scenario #1
Clarice, the clinical manager of a neuroscience unit in a large acute care hospital, recently hired a new nurse, Danielle, who has extensive experience in long-term care settings. Danielle’s therapeutic skills are extremely strong, but she struggles with certain aspects of medication administration. Clarice meets with Danielle and together they develop a learning plan to address the areas of concern. Unfortunately, Danielle’s near-miss errors continue. Clarice decides that Danielle must be paired with a more senior nurse on the unit, and informs the facility operator of the steps she has taken to have Danielle supervised. The facility operator then reports Danielle’s situation to the College.
Facility operators are required to report to the College when there is reason to believe that a nurse who practises at the facility is incompetent. The definition of incompetence includes three key components:
- it must relate to the nurse’s professional care of a patient;
- the nurse must display a lack of knowledge, skill or judgment; and
- the deficiencies must be of a nature or to an extent that demonstrates that the nurse is unfit to continue to practise, or that their practice should be restricted.
In this case, Danielle’s deficiencies in the areas of medication administration are of a degree that her employer has placed limitations on her ability to practise independently. Further, it appears that, at this time, the remedial measures have not resulted in significant improvement.
Reporting Incompetence: Scenario #2
Stacy is a new graduate nurse working in the general medicine unit. She has been working on a probationary basis for the past three months. During this time, Stacy has made several serious medication errors. Despite going through remediation and working buddied shifts with senior nurses, Stacy recently made another medication error. Stacy takes accountability for her errors and states that she sometimes has difficulty concentrating. Her employer decides to terminate Stacy due to her unsafe practice, but does not want to report her to CNO out of fear that it may jeopardize her nursing career. What should the employer do?
Under the Regulated Health Professions Act, 1991, employers are obligated to report to CNO the termination or the intent to terminate a nurse’s employment for reasons of professional misconduct, incapacity or incompetence.
Stacy’s employer is required to alert CNO that Stacy is not practicing safely and report details about her termination. After receiving the report, CNO will complete an initial assessment. Once this process is complete, CNO’s Executive Director reviews the report along with any other information gathered about Stacy. The Executive Director assesses the level of risk to the public and determines an appropriate regulatory response.
It is important to recognize that the intent of mandatory reporting is not to punish nurses, but to ensure public safety within a framework that supports nurses to return to safe practice where possible. In the event of an investigation, the information will be reviewed by the Inquiries Complaints Resolution Committee (ICRC).
Reporting sexual abuse: scenario #1
The manager was informed by the day shift nurse that a patient had told her that the night nurse, Andrew, had touched her inappropriately while providing care. Andrew was immediately put on leave pending an investigation. Andrew has been with the facility for close to a decade and this is the first complaint a patient has ever made about his practice or conduct. Andrew’s most recent performance reviews even note that he is an excellent nurse who is a strong advocate for his patients. Does a report have to be made before the employer’s investigation is completed? What if the employer’s investigation finds no cause for concern?
All members of regulated health professions, including employers and nurses, have an obligation to report to the relevant regulatory body if there are grounds to believe that a patient has been sexually abused by a health care professional. This means that if you have received information from any source that a patient described a specific incident of sexual abuse, then you have a mandatory reporting obligation to the CNO.
Reporting should be not delayed as the obligation to report is not dependent on the outcome of the facility or employer investigation. In making a report to the College, you are not determining that sexual abuse has occurred; you are reporting that it may have occurred. It is the College's obligation to assess and determine the appropriate response to the reported information, in the public interest.
Reporting Sexual Abuse: Scenario #2
An Executive Director of a community hospital recently discovered that a nurse on the step-down cardiac unit has started a relationship with her patient. The Executive Director has obtained screenshots of their interactions on social media. The nurse denies this relationship as does the patient. What is the Executive Director’s accountability as this nurse’s employer and the facility operator?
According to the Protecting Patients Act, 2017 (Bill 87), any sexual contact between a nurse and a patient or former patient within one-year following the end of the therapeutic nurse-client relationship is sexual abuse. It does not matter if the patient consented to the sexual acts. This accountability is also outlined in the Code of Conduct.
Facility operators and other regulated health professionals are accountable for reporting incidents of sexual abuse to CNO within 30 days. In this case, the Executive Directorhas a legal obligation to report to CNO within 30 days of receiving information that a nurse has sexually abused a client.
Non-Mandatory Reporting: Scenario #1
A nursing home administrator received several complaints from patients and staff that Nurse Jim is rude and disrespectful. Jim is otherwise competent in his clinical practice. The nursing home administrator asks Jim to complete a learning plan and review the practice standards, Professional Standards and Therapeutic Nurse Client Relationship. There is no intention of terminating Jim. Is there an obligation for the nursing home administrator to report Jim’s unprofessional behavior to CNO?
While reporting obligations are clear, it is sometimes difficult to decide if other concerns should be reported to CNO. Employers are responsible for determining if remediation is warranted and should assess the outcomes. If concerns remain, however, it may be appropriate to submit a report to CNO.
Although rude and disrespectful behavior does not fall under the requirements of mandatory reporting (unless the nurse has been terminated), Jim’s behavior does not align with nurses’ accountabilities to conduct themselves in ways that promote respect for the profession and provide the best possible care for patients. These accountabilities are outlined in the Code of Conduct and the Professional Standards, Revised 2002. In this case, the nursing home administrator may file a non-mandatory report to CNO.
All reports, including non-mandatory reports, are reviewed by CNO’s Executive Director who will assess the level of risk the reported incidents could pose to the public and will determine an appropriate regulatory response.