Regulation of The Nursing Profession Addressing Complaints

Regulation of the Nursing Profession
Addressing Complaints
http://www.cno.org/globalassets/docs/prac/41062.pdf
Utilization of RNs and RPNs learning module
The College of Nurses of Ontario presents the
Utilization of RNs and RPNs practice guideline:
The Three Factor Framework;

Nurse factors
Client factors
Environmental factors
Copyright © 2010 Elsevier Canada, a division of Reed

Elsevier Canada, Ltd.
The Three Factor Framework
Nurse Factors
• Autonomous practice is the ability to make
decisions and independently carry out
nursing responsibilities.
• RNs meet the nursing needs of clients
regardless of the complexity of their
conditions and in all practice environments.
• RPNs have greater autonomy when caring for
clients with less complex conditions. RPNs
require consultation and collaboration to
meet more complex client care needs.
Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
The Three Factor Framework
Client factors
• Client care requirements are influenced by
the:
• complexity of care needs;
• predictability of outcomes of client care;
and
• risk of negative outcomes in response to
care.
• Complexity of care needs; Less complex,
Moderately complex, Highly complex
Client factors
To determine the level of complexity, ask:

Are the care needs well defined?
Are there multiple issues?
Does the client require frequent monitoring or reassessment?
Is there a risk of negative outcomes?
Are there support systems in place?
Predictability of outcomes of client care

Predictable, Moderately predictable, Unpredictable
To determine the level of predictability, consider the: possible
changes in health condition; timing; and nature of the
outcomes.
Client factors
Care requirements are considered predictable when outcomes and
changes are predictable.
For example, a client who has had paraplegia for many years and
whose health condition is stable has well-established care needs, and the
outcomes are predictable.
Care requirements are moderately predictable when the client’s health
condition may not be controlled or managed as well; identifiable
changes could occur and the timing may be unpredictable.
For example, a client with asthma can have symptoms that worsen
on exposure to allergens.
Care requirements are unpredictable when the outcomes and change
in health condition are unpredictable.
For example, a client with acute heart failure and uncontrolled
diabetes has highly complex care needs because the change in health
condition, both in timing and the nature of the outcomes, is difficult to
predict

Client factors
There is a low risk of negative outcomes when the signs

and symptoms are obvious and the responses to care are
predictable, localized and manageable.
• An example of a low-risk situation is administering

blood products to a client who has chronic anemia and
regularly receives an infusion of red blood cells with no
history of adverse reactions
• An example of a moderate-risk situation is
administering blood products to a client known to have
reactions during infusion
• An example of a high-risk situation is a client who is
admitted with an acute gastrointestinal bleed who has
never received a blood transfusion.

Environmental factors
Practice supports - supports has policies, parameters

and pre-developed care plans, but is limited in the
number of expert nurses familiar with the practice setting
Consultative resources - obtaining information, advice

or assistance from a more experienced or knowledgeable
nurse or health care provider
Stability and predictability - range from stable and

predictable, to unstable and unpredictable

Differences Between Registered and Practical Nurses
RNs RPNs/LPNs
Have more in-depth education, Have a more basic education,
usually at the university level usually at a community
college
Care for more complex and Care for more stable patients
unpredictable client with more predictable
populations conditions
Have more opportunities to Have fewer opportunities to

specialize specialize

Regulatory Bodies
 In most provinces
◦ RNs and RPNs/LPNs are governed by different regulatory
bodies
◦ the regulatory arm (which regulates entry to practice) and
the professional arm (which advocates for members) are
combined
 In Ontario
◦ RNs and RPNs are governed by the College of Nurses of
Ontario
◦ separate associations (RNAO, RPNAO) perform the
professional advocacy role
There is also a National Professional Organization of Nurses,

known as the Canadian Nurses Association (CNA)
Duties and Objectives of Regulatory Bodies
The foremost duty of all regulatory

bodies is to protect the public interest
Objectives are to regulate

• roles, education, and entry into the profession
• scope of practice
• standards of practice
• complaints processes
• discipline of non-compliant members
Internationally Educated Nurses
In most provinces, an internationally

educated nurse must provide evidence of
• English proficiency (or French in
Quebec)
• registration in the country where he or
she studied nursing
• good character (i.e., no criminal record)

Unauthorized Practise and Use of Titles
All provinces and territories restrict the
practice of nursing, and use of titles, to
members in good standing
A member who is under suspension or whose

certificate has been revoked may not use a title
or practise nursing
Continuing to practise while under suspension

constitutes professional misconduct

Addressing Complaints
http://www.cno.org/globalassets/docs/ih/42017_r
esolvingcomplaints.pdf
Who can complain to the College?
Complaints can come from patients and other members of
the public.
What should you do if you have concerns that the care

provided by a nurse has not met the standards?
You have the right to express your concerns about nurses
to the College.
The College is required by law to respond to all
complaints about nursing care.
Slide 15
Addressing Complaints at the College of
Nurses of Ontario
Purpose of the complaints process
• protects the public and improves nursing

practice.
• the complaints process presents nurses with the
chance to demonstrate accountability for their
practice
• provides you with a opportunity to work with the
College in the resolution of your complaint.

What is a complaint?
The College can address your

complaints when:
• the person you’ve complained about is a nurse; and
• your concern is about a breach of, or failure to meet,
the practice standards expected by the College, the
nursing profession and the public.
• About any aspect of nursing care. Examples include
complaints about giving medication unsafely, taking
money, being rough with a patient and any form of
sexual abuse.
Types of complaints
The types of concerns the College can address include:
• failure to provide adequate care;
• unsafe medication administration;
• inadequate documentation;
• being sarcastic to, or swearing, teasing or yelling at, a
client;
• using restraints without consent or unnecessarily;
handling a client in a rough manner;
• having a romantic or sexual relationship with a client;
• asking for or borrowing money from a client;
• not protecting a client’s privacy; and
• theft.
The College does not have jurisdiction to
address concerns about nurses when:
• the issues in the complaint have already been resolved by
another agency (e.g., the outcome of a Workers Safety
Insurance Board claim);
• the complaint is about a nurse’s personal life, such as her or
his behaviour as a spouse, parent, family member,
neighbour or business partner, unless the behaviour directly
and negatively affects the nursing care she or he provides or
the integrity of the profession;
• the complaint is about systems or business practices within a
health care facility, institution or agency; and
• the complaint is made in bad faith or retaliation.
• the complaint is unsigned (made anonymously) and the
College cannot get any further information.
What happens when someone wants to
make a complaint?
Should be in permanent form.
It can’t take complaints over the phone.
The complaint can be written or recorded (audio or
video), and should include:
the name and complete contact information of the
person making the complaint, called the
complainant.
And all complaint details, where and when the issue
took place and the name of the nurse involved.
The College acknowledge receipt of the complaint and
explains the complaints process.
Slide 20
Addressing complaints
Alternative Dispute Resolution: The
Resolution Process
• allow the College's Executive Director to make
referrals to the alternative dispute resolutions
(ADRs) process.
• is to protect the public, not to determine what
happened or to lay blame.
• Nurses expected to act in good faith
• All resolution agreements must be approved by
the Inquiries, Complaints and Reports
Committee (ICRC). College staff ensure that the
nurse fulfils her or his commitments
Alternative dispute resolution
This process is faster, and more satisfactory results are
reported for both the complainant and the nurse involved.
This is because they each play a big role in how the complaint
is addressed.
Both parties should agree
A trained facilitator from the College talks separately with the
complainant and the nurse.
They discuss the complaint and exchange ideas for
resolving it.
This is an opportunity for nurses to show they are willing
to keep learning and striving to maintain and exceed the
College’s standards of practice. At the College, this is
called reflective practice
Slide 22
Alternative dispute resolution
The facilitator drafts a resolution agreement, which is signed
by all parties: the complainant, the nurse or nurses, and the
College
For the nurse, signing means they must fulfill the terms of
their agreement.
Everything in an alternative dispute resolution process stays
confidential.
A resolution agreement is not published in the College’s
public register or made available to any current or future
employer
Goes through the investigation process, if can’t be dealt

with through ADR
Slide 23
There are two types of investigations that may
take place at the College
Complaints investigation
• define the scope of the investigation and the issues to
be explored
Executive Director’s investigations

• the Executive Director may appoint an investigator
after determining that there are reasonable and
probable grounds to believe that a member has
committed an act of professional misconduct or is
incompetent
Investigations
- The investigator will request the member’s written
submissions.
- The member has 30 days to provide a response.

- Once the investigation is complete, the results are reviewed
by a Panel of the ICRC.
- The ICRC will provide you with the reasons for their
decision. A small percentage of complaints (about five percent
of investigations per year) involve very serious matters and
are referred to the Discipline Committee
- If your complaint is not appropriate for the resolution
process, a College investigator will be appointed to the case

Panel of the ICRC will:
• refer specified allegations to the Discipline Committee for
a hearing;
• make further inquiries as to whether the nurse is suffering
from a physical or mental condition that affects his/her
capacity to practise safely;
• require the nurse to appear before a Panel of the ICRC to
be cautioned;
• take other appropriate action such as requiring the nurse
to undergo continuing education or remediation and/or
• take no action.

Public hearings
Hearings at the College are much like proceedings in a

court of law.
If the ICRC refers your complaint to the Discipline

Committee, the College will present evidence before a
Panel consisting of nurses and members of the public
whose role is similar to that of a jury
Note that the Panel is independent of the College.

College have no influence on Panels’ decisions

Outcomes of hearings
Depending on the severity of the case, the Panel
can order the nurse to do one or more of the
following:
• pay a fine to the Ontario government (not the College
or the complainant);
• appear in person for a reprimand delivered by the
Panel;
• complete remedial education;
• place conditions a nurse’s practice;
• suspend the nurse from working for a set period of
time; and/or,
• in the most serious cases (especially sexual abuse),
revoke the nurse’s ability to practise nursing.

Outcomes of hearings
If your complaint results in a hearing

before the Discipline Committee, you will
receive a copy of the Panel’s decisions and
reasons after the matter is concluded.
In addition, the results of all disciplinary

hearings are published in the College’s
membership magazine, The Standard,
and are made public on the College’s web
site at www.cno.org/decisions.
Disciplinary and Competency Matters
Disciplinary proceedings against

nurses are
• governed by the nursing regulatory body
• designed to ensure nurses’ professional conduct
conforms to ethical codes and regulations
• investigated, and if warranted, referred to
appropriate committees for hearing
Disciplinary proceedings are not

criminal proceedings
Disciplinary Proceedings
The College’s disciplinary
processes give the public The Discipline
an opportunity to voice Committee has a
its concerns about number of options,
nursing services. including the power;
• Takes place when a • to revoke

nurse breaches the • suspend and/or
standards of practice of • put terms, conditions
the profession. and limits on a nurse’s
• Are used to address registration.
serious cases of
misconduct and
incompetence

Disciplinary Proceedings
Only a Discipline Panel can make a finding of
professional misconduct or
incompetence.
Examples of professional misconduct may
include:
• the violation of the ethical standards set out for the

profession;
• breaches to the standards of practice;
• breaches to the therapeutic nurse-client relationship;
and
• physical, emotional, verbal or sexual abuse.

Procedures for Disciplinary Hearings
The procedures are generally as follows:
complaint in writing
investigation
interim investigation
disciplinary committee hearing
Complaint in Writing
Complaints of professional misconduct
• must be in writing, and be signed and dated
• name the health professional alleged to have acted
unprofessionally
• outline the facts of the alleged misconduct
• may be filed by nursing or other colleagues, patients or their
family members, or employers
Investigation
Investigation
Members who are the subject of an investigation
must be notified of the complaint immediately
are entitled to submit documents or information for
consideration
have a legal duty to cooperate with the investigation
should consult a lawyer without delay
Interim Investigation
If well founded, the complaint may be referred to a disciplinary
committee for further investigation and a hearing
If allegations relate to patient safety or security, the committee
may suspend the nurse’s right to practise

Discipline Process
a) Pre-hearing Conference
chaired by a member of the Discipline Committee, is attended
by the representative of the College, the prosecutor, defence
counsel and/or the nurse
The purpose of this conference is:
to narrow the issues for the hearing
to identify legal and procedural issues for the panel
to provide the parties with the opportunity to receive a candid
assessment of the case and
to assist with a resolution on some or all of the matters
b) Disciplinary Hearing
A discipline panel may be composed of three to five people. At
least two of the panel members are public members of the
College’s Council. The remaining three panel members are
nurses, two of whom are generally of the same category (RN or
RPN) as the nurse facing the allegation
Discipline Process
The discipline panel will:
• consider the allegations, hear the evidence
and determine the facts of the case;
• determine whether the evidence proves the
allegation;
• determine whether the member has
committed an act of professional
misconduct or is incompetent; and
• determine the penalty to be imposed in
cases where such findings have been made.
Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada,

Disciplinary Committee Hearing
The committee, after hearing the evidence,

may find that the nurse is
• innocent of any wrongdoing
• incompetent, unskilled, or lacking in
essential knowledge
• guilty of professional misconduct
• habitually impaired by alcohol or drugs,
and therefore unable to perform his or
her duties and obligations
Penalties/hearing outcomes/Appeals
Penalties may include:
- censure or reprimand, orally or in writing
- conditions placed on the nurse’s right to practise, such as
additional courses or examinations
- suspension
- permanent revocation of license to practise
Appeals
A nurse found guilty of professional misconduct may appeal the
decision, the penalty, or both within a certain timeframe
In some provinces, an unfavourable appeal can be taken to
provincial courts for a new hearing
In other provinces and territories, judicial review may occur in
certain circumstances
Fitness to Practise Committees
In Ontario, while investigating a member’s capacity, the
committee will appoint a Board of Inquiry, which may
order
- physical or psychological examinations
- the suspension of practice, pending inquiry
A finding of incapacity will result in revocation or
suspension of registration until certain conditions are met

Controlled Acts
In most provinces and territories, the law
defines
• which medical actions and procedures may be
performed
• who may perform and delegate them
Exemptions exist to allow

• Non-regulated persons to perform acts to assist a
person with routine activities of daily living
• acts done to treat a person by spiritual means

Standards of Practice
Practice standards
• are established by all regulatory bodies across
Canada
• reflect the philosophy of nursing practice and
ethical codes
• are relevant to malpractice and negligence
issues
• provide directly relevant evidence of the
standard of care
• provide criteria by which a nurse’s conduct will
be judged in legal or disciplinary proceedings

Standards of Practice
Most standards of practice
• provide a guide for safe practice

• describe nurses’ responsibilities and
accountabilities
• provide performance criteria and ensure
continuing competence
• interpret scope of practice
• provide direction for nursing education and
research-based practice
• facilitate peer review and quality improvement
Ongoing Competence
Nursing regulatory bodies have mechanisms in place

to ensure the ongoing competence of nurses
Some provinces have reflective practice models which

involve self or peer reviews of practice (or both) and
identification of strengths and learning opportunities
Other provinces have minimum practice hours and

personal practice reviews

Criminal Background Checks
Regulatory bodies and employers are legally

obligated to perform background checks on
nursing candidates and nurses. It is important to
note that
• the intent of such procedures is to exclude
those who pose a threat to the safety of others
• a criminal record may not preclude registration
or employment. Consideration is given to
• the nature of the offence
• when the offence occurred

Summary
It is important for the student to review the regulations

in his or her province
It is essential that nurses understand the expectations

associated with being a member of a regulated
profession and the responsibilities and obligations that
come with the privilege.
These standards are significant not only in the ongoing

evaluation of nurses with respect to safe, competent, and
ethical care but also in measuring the nurse’s behaviour
with respect to legal and professional expectations.

Regulation of The Nursing Profession Addressing Complaints

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Regulation of the Nursing Profession

The Three Factor Framework;

Copyright © 2010 Elsevier Canada, a division of Reed

To determine the level of complexity, ask:

Predictability of outcomes of client care

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

There is a low risk of negative outcomes when the signs

• An example of a low-risk situation is administering

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Practice supports - supports has policies, parameters

Consultative resources - obtaining information, advice

Stability and predictability - range from stable and

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Have more opportunities to Have fewer opportunities to

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

There is also a National Professional Organization of Nurses,

The foremost duty of all regulatory

Objectives are to regulate

In most provinces, an internationally

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

A member who is under suspension or whose

Continuing to practise while under suspension

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

What should you do if you have concerns that the care

Purpose of the complaints process

• protects the public and improves nursing

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

The College can address your

Goes through the investigation process, if can’t be dealt

Executive Director’s investigations

- The member has 30 days to provide a response.

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Copyright © 2010 Elsevier Canada, a division of Reed

Hearings at the College are much like proceedings in a

If the ICRC refers your complaint to the Discipline

Note that the Panel is independent of the College.

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

If your complaint results in a hearing

In addition, the results of all disciplinary

Disciplinary proceedings against

Disciplinary proceedings are not

• Takes place when a • to revoke

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

• the violation of the ethical standards set out for the

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada,

The committee, after hearing the evidence,

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Exemptions exist to allow

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

• provide a guide for safe practice

Nursing regulatory bodies have mechanisms in place

Some provinces have reflective practice models which

Other provinces have minimum practice hours and

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Regulatory bodies and employers are legally

Copyright © 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

It is important for the student to review the regulations

It is essential that nurses understand the expectations

These standards are significant not only in the ongoing