JURISPREDENCE EXAM
1. About the CNO
 regulates approximately 160000 nurses in ON
 regulates nurses in the public interest
 The Regulated Health Professions Act, 1991 and the Nursing Act, 1991 provide
the legislative framework for regulating nursing in Ontario
 The college’s role:
1. Articulating & promoting practice standards
2. Establishing entry to practice requirements
3. QA program
4. Enforcing standards of practice and conduct
 The College’s governing Council is composed of nurses elected by their peers and
members of the public appointed by the provincial government. Council
establishes, in accordance with legislation, the goals and objectives of the College
 Five Statutory Committees:
1. Discipline: Holds hearings in cases in which a member of the College has
been referred by the Inquiries, Complaints and Reports Committee
because of the serious nature of alleged professional misconduct and/or
incompetence.
2. Fitness to practice: Determines whether a nurse is suffering from a
physical or mental condition or disorder that is affecting, or could affect,
her or his practice
3. Inquiries, Complaints and Reports: Screens matters related to public
complaints or information the College receives
4. QA: Responsible for ensuring that members comply with all aspects of the
QA program
5. Registration: Determines whether applicants are qualified to practise
nursing in Ontario
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2. Entry to Practice Competencies (RN)
 Entry-level competencies for RNs were first published by CNO in 2005 to align with the
regulation change toward a university baccalaureate education requirement for RNs in
Ontario
 In 2017, the Canadian Council of Registered Nurse Regulators initiated the most recent
review and revisions of entry-to-practice competencies for registered nurses in Canada.
The initiative was led by a working group comprised of 11 provincial and territory
 Overarching Principles:
o Entry-level RNs are beginning practitioners. It is unrealistic to expect an entrylevel RN to function at the level of practice of an experienced RN
o Entry-level RNs work within the registered nursing scope of practice, and
appropriately seek guidance when they encounter situations outside of their ability
o Entry-level RNs must have the requisite skills and abilities to attain the entrylevel competencies
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o Entry-level RNs are prepared as generalists to practice safely, competently,
compassionately, and ethically
 in situations of health and illness
 with all people across the lifespan
 with all recipients of care: individuals, families, groups, communities, and
populations
 across diverse practice settings
 using evidence-informed practice
o Entry-level RNs have a strong foundation in nursing theory, concepts and
knowledge, health and sciences, humanities, research, and ethics from education
at the baccalaureate level
o Entry-level RNs practice autonomously within legislation, practice standards,
ethics, and scope of practice in their jurisdiction
o Entry-level RNs apply the critical thinking process throughout all aspects of
practice.
Definition of a Client:
o The client is the central focus of registered nursing practice. In the context of this
document, “client” refers to a person who receives services from a registered
nurse. In most circumstances, the client is an individual, but the client can also
include family members or substitute decision-makers. A client can also be a
group, community, or population.
Competencies
o Clinician
Registered nurses are clinicians who provide safe, competent, ethical,
compassionate, and evidence-informed care across the lifespan in response to
client needs. Registered nurses integrate knowledge, skills, judgment, and
professional values from nursing and other diverse sources into their practice.
1.1 Provides safe, ethical, competent, compassionate, client-centred and evidence
informed nursing care across the lifespan in response to client needs. 1.2
Conducts a holistic nursing assessment to collect comprehensive information on
client health status.
1.3 Uses principles of trauma-informed care which places priority on trauma
survivors’ safety, choice, and control.
1.4 Analyses and interprets data obtained in client assessment to inform ongoing
decision-making about client health status.
1.5 Develops plans of care using critical inquiry to support professional judgment
and reasoned decision-making.
1.6 Evaluates effectiveness of plan of care and modifies accordingly.
1.7 Anticipates actual and potential health risks and possible unintended
outcomes.
1.8 Recognizes and responds immediately when client safety is affected.
1.9 Recognizes and responds immediately when client’s condition is deteriorating
1.10 Prepares clients for and performs procedures, treatments, and follow up care.
1.11 Applies knowledge of pharmacology and principles of safe medication
practice.
1.12 Implements evidence-informed practices of pain prevention, manages
client’s pain, and provides comfort through pharmacological and nonpharmacological interventions.
1.13 Implements therapeutic nursing interventions that contribute to the care and
needs of the client.
1.14 Provides nursing care to meet palliative and end-of-life care needs.
1.15 Incorporates knowledge about ethical, legal, and regulatory implications of
medical assistance in dying (MAiD) when providing nursing care.
1.16 Incorporates principles of harm reduction with respect to substance use and
misuse into plans of care.
1.17 Incorporates knowledge of epidemiological principles into plans of care.
1.18 Provides recovery-oriented nursing care in partnership with clients who
experience a mental health condition and/or addiction.
1.19 Incorporates mental health promotion when providing nursing care.
1.20 Incorporates suicide prevention approaches when providing nursing care.
1.21 Incorporates knowledge from the health sciences, including anatomy,
physiology, pathophysiology, psychopathology, pharmacology, microbiology,
epidemiology, genetics, immunology, and nutrition.
1.22 Incorporates knowledge from nursing science, social sciences, humanities,
and health-related research into plans of care.
1.23 Uses knowledge of the impact of evidence informed registered nursing
practice on client health outcomes.
1.24 Uses effective strategies to prevent, de-escalate, and manage disruptive,
aggressive, or violent behaviour.
1.25 Uses strategies to promote wellness, to prevent illness, and to minimize
disease and injury in clients, self, and others.
1.26 Adapts practice in response to the spiritual beliefs and cultural practices of
clients.
1.27 Implements evidence-informed practices for infection prevention and
control.
o Professional
Registered nurses are professionals who are committed to the health and wellbeing of clients. Registered nurses uphold the profession’s practice standards and
ethics and are accountable to the public and the profession
2.1 Demonstrates accountability, accepts responsibility, and seeks assistance as
necessary for decisions and actions within the legislated scope of practice.
2.2 Demonstrates a professional presence, and confidence, honesty, integrity, and
respect in all interactions.
2.3 Exercises professional judgment when using agency policies and procedures,
or when practising in their absence.
2.4 Maintains client privacy, confidentiality, and security by complying with
legislation, practice standards, ethics, and organizational policies.
2.5 Identifies the influence of personal values, beliefs, and positional power on
clients and the health care team and acts to reduce bias and influences.
2.6 Establishes and maintains professional boundaries with clients and the health
care team.
2.7 Identifies and addresses ethical (moral) issues using ethical reasoning, seeking
support when necessary.
2.8 Demonstrates professional judgment to ensure social media and information
and communication technologies (ICTs) are used in a way that maintains public
trust in the profession.
2.9 Adheres to the self-regulatory requirements of jurisdictional legislation to
protect the public by
a) assessing own practice and individual competence to identify learning
needs.
b) developing a learning plan using a variety of sources
c) seeking and using new knowledge that may enhance, support, or
influence competence in practice
d) implementing and evaluating the effectiveness of the learning plan and
developing future learning plans to maintain and enhance competence as
a registered nurse.
2.10 Demonstrates fitness to practice.
2.11 Adheres to the duty to report.
2.12 Distinguishes between the mandates of regulatory bodies, professional
associations, and unions.
2.13 Recognizes, acts on, and reports, harmful incidences, near misses, and no
harm incidences.
2.14 Recognizes, acts on, and reports actual and potential workplace and
occupational safety risks.
o Communicator
Registered nurses are communicators who use a variety of strategies and relevant
technologies to create and maintain professional relationships, share information,
and foster therapeutic environments.
3.1 Introduces self to clients and health care team members by first and last name,
and professional designation (protected title).
3.2 Engages in active listening to understand and respond to the client’s
experience, preferences, and health goals.
3.3 Uses evidence-informed communication skills to build trusting,
compassionate, and therapeutic relationships with clients.
3.4 Uses conflict resolution strategies to promote healthy relationships and
optimal client outcomes.
3.5 Incorporates the process of relational practice to adapt communication skills.
3.6 Uses information and communication technologies (ICTs) to support
communication.
3.7 Communicates effectively in complex and rapidly changing situations.
3.8 Documents and reports clearly, concise, and in a timely manner
o Collaborator
Registered nurses are collaborators who play an integral role in the health care
team partnership
4.1 Demonstrates collaborative professional relationships.
4.2 Initiates collaboration to support care planning and safe, continuous
transitions from one health care facility to another, or to residential, community or
home and self-care.
4.3 Determines their own professional and interprofessional role within the team
by considering the roles, responsibilities, and the scope of practice of others.
4.4 Applies knowledge about the scopes of practice of each regulated nursing
designation to strengthen intraprofessional collaboration that enhances
contributions to client health and well-being.
4.5 Contributes to health care team functioning by applying group communication
theory, principles, and group process skills.
o Coordinator
Registered nurses coordinate point-of-care health service delivery with clients, the
health care team, and other sectors to ensure continuous, safe care.
5.1 Consults with clients and health care team members to make ongoing
adjustments required by changes in the availability of services or client health
status.
5.2 Monitors client care to help ensure needed services happen at the right time
and in the correct sequence.
5.3 Organizes own workload, assigns nursing care, sets priorities, and
demonstrates effective time management skills
5.4 Demonstrates knowledge of the delegation process.
5.5 Participates in decision-making to manage client transfers within health care
facilities.
5.6 Supports clients to navigate health care systems and other service sectors to
optimize health and well-being.
5.7 Prepares clients for transitions in care.
5.8 Prepares clients for discharge.
5.9 Participates in emergency preparedness and disaster management.
o Leader
Registered nurses are leaders who influence and inspire others to achieve optimal
health outcomes for all.
6.1 Acquires knowledge of the Calls to Action of the Truth and Reconciliation
Commission of Canada.
6.2 Integrates continuous quality improvement principles and activities into
nursing practice.
6.3 Participates in innovative client-centred care models.
6.4 Participates in creating and maintaining a healthy, respectful, and
psychologically safe workplace.
6.5 Recognizes the impact of organizational culture and acts to enhance the
quality of a professional and safe practice environment.
6.6 Demonstrates self-awareness through reflective practice and solicitation of
feedback.
6.7 Takes action to support culturally safe practice environments.
6.8 Uses and allocates resources wisely.
6.9 Provides constructive feedback to promote professional growth of other
members of the health care team.
6.10 Demonstrates knowledge of the health care system and its impact on client
care and professional practice.
6.11 Adapts practice to meet client care needs within a continually changing
health care system
o Advocate
Registered nurses are advocates who support clients to voice their needs to
achieve optimal health outcomes. Registered nurses also support clients who
cannot advocate for themselves.
7.1 Recognizes and takes action in situations where client safety is actually or
potentially compromised.
7.2 Resolves questions about unclear orders, decisions, actions, or treatment. 7.3
Advocates for the use of Indigenous health knowledge and healing practices in
collaboration with Indigenous healers and Elders consistent with the Calls to
Action of the Truth and Reconciliation Commission of Canada.
7.4 Advocates for health equity for all, particularly for vulnerable and/or diverse
clients and populations.
7.5 Supports environmentally responsible practice.
7.6 Advocates for safe, competent, compassionate and ethical care for clients. 7.7
Supports and empowers clients in making informed decisions about their health
care, and respects their decisions.
7.8 Supports healthy public policy and principles of social justice.
7.9 Assesses that clients have an understanding and ability to be an active
participant in their own care, and facilitates appropriate strategies for clients who
are unable to be fully involved.
7.10 Advocates for client’s rights and ensures informed consent, guided by
legislation, practice standards, and ethics.
7.11 Uses knowledge of population health, determinants of health, primary health
care, and health promotion to achieve health equity.
7.12 Assesses client’s understanding of informed consent, and implements actions
when client is unable to provide informed consent.
7.13 Demonstrates knowledge of a substitute decision maker’s role in providing
informed consent and decision-making for client care.
7.14 Uses knowledge of health disparities and inequities to optimize health
outcomes for all clients
o Educator
Registered nurses are educators who identify learning needs with clients and
apply a broad range of educational strategies towards achieving optimal health
outcomes.
8.1 Develops an education plan with the client and team to address learning
needs.
8.2 Applies strategies to optimize client health literacy.
8.3 Selects, develops, and uses relevant teaching and learning theories and
strategies to address diverse clients and contexts, including lifespan, family, and
cultural considerations.
8.4 Evaluates effectiveness of health teaching and revises education plan if
necessary.
8.5 Assists clients to access, review, and evaluate information they retrieve using
information and communication technologies (ICTs).
o Scholar
Registered nurses are scholars who demonstrate a lifelong commitment to
excellence in practice through critical inquiry, continuous learning, application of
evidence to practice, and support of research activities.
9.1 Uses best evidence to make informed decisions.
9.2 Translates knowledge from relevant sources into professional practice.
9.3 Engages in self-reflection to interact from a place of cultural humility and
create culturally safe environments where clients perceive respect for their unique
health care practices, preferences, and decisions.
9.4 Engages in activities to strengthen competence in nursing informatics.
9.5 Identifies and analyzes emerging evidence and technologies that may change,
enhance, or support health care.
9.6 Uses knowledge about current and emerging community and global health
care issues and trends to optimize client health outcomes.
9.7 Supports research activities and develops own research skills.
9.8 Engages in practices that contribute to lifelong learning.
2. Ask Practice
 Ask Practice features questions and answers about a variety of practice-related issues that
nurses may face over the course of their careers:
o TOA
 I’m a nurse working on an in-patient medical surgical unit. We have
decided to focus on improving communication during shift report,
including when a nurse goes on a break. What are nurses’
accountabilities when giving reports?
 Nurses are accountable for facilitating, advocating and promoting the best
possible care for clients. Nurses must also take action if client safety and
well-being are compromised. These are important accountabilities stated
in the practice standards, Professional Standards, Revised
2002 and Therapeutic Nurse-Client Relationship, Revised 2006.
 Care transitions involve the process of communicating client-specific
information from one caregiver to another, or from one team of caregivers
to another, to ensure continuity of care and client safety. Transfer of
accountability — or providing “report” or “handover” — is a crucial
component of the care transition process.
 Care transitions happen often, such as when a client experiences a change
in location or health care providers. They also include when shifts end, or
when nurses go on break.
 During the transfer of care or “handover,” there is a potential for
miscommunicating client information. To minimize this risk, each time
care is transferred, nurses must communicate client-specific information to
a colleague that is clear, client-focused, and comprehensive. This
accountability is outlined in principle 4.2 of the Code of Conduct.
 During care transitions, nurses must ensure that they do not discuss client
information in public places such as elevators, cafeterias or hallways. For
more information, see the Confidentiality and Privacy: Personal Health
Information practice standard.
 When communicating to another care provider when transferring
accountability, ask yourself:
 What information does another care provider need to know to provide safe
care?
 Is the information I am providing clear, client-focused and
comprehensive?
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o Code Silver
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Have I worked with the client and the health care team to develop a care
plan that promotes client safety and continuity of care during the care
transition?
How does our current practice contrast with best practice evidence, such
as RNAO’s Care Transitions best practice guideline?
CNO expects all nurses to be aware of relevant organizational policies and
procedures regarding care transitions, including transfer of accountability.
If the need exists, nurses may wish to work with their employer to develop
such policies in the interest of client safety.
All members of the health care team have a shared accountability to
advocate for quality practice environments that support nurses’ abilities to
provide safe care.
My employer recently introduced a ‘Code Silver’ policy in my
organization, which directs employees to run, hide and survive when
there is a combative individual with a lethal weapon on the premises.
Do I have the right to refuse to provide care to clients in hazardous
situations, where the hazard is workplace violence?
This depends on the context and factors surrounding a particular practice
situation. Under the Nursing Act, 1991, it is considered professional
misconduct to discontinue professional services that a client needs, unless:
the client requests the discontinuation
alternative or replacement services are arranged, or
the client is given reasonable opportunity to arrange alternative or
replacement services
However, in emergencies, such as a ‘Code Red’ response to fire, the
College does not expect nurses to put their lives or personal safety at risk
when caring for clients.
Refusing to work during an emergency situation that places a nurse’s life
in danger is not the type of situation that was intended by the
“discontinuation of services” in the Nursing Act.
Under the Occupational Health and Safety Act, employers are also
accountable for establishing a safe work environment and minimizing real
or potential risks to employees and clients alike. The College encourages
nurses to work collaboratively with their employers to appreciate real or
potential threats, review relevant organizational policies, and if needed,
develop policies and guidelines that are specific to the practice setting and
driven by client interests and safety.
For more information on maintaining a quality practice setting and
guidelines for decision-making, read Refusing Assignments and
Discontinuing Nursing Services & Ethics.
o Communicating Test Results
 All nurses — RNs, RPNs and NPs — can communicate test results and
health conditions (such as pregnancy) that are neither diseases nor
disorders. As well, all nurses can communicate findings from an
assessment to patients. Nurses should ensure they are not communicating
a diagnosis to patients when discussing test results or assessment findings,
unless it has been formally delegated by an NP or physician. When
appropriate, you can recommend that patients follow up with an NP or
their physician to receive the definitive diagnoses.
o Continuing Competence
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I’m a nurse with emergency department experience. I have decided I
would like to specialize in wound care. What certifications and
courses does CNO require me to take?
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As self-reflective and self-regulating health professionals, nurses are
accountable for determining their individual learning needs and what best
helps them achieve their objectives (for example, taking refresher courses
or obtaining certifications). CNO does not approve or endorse specific
continuing education programs or certifications.
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Employers also may require certain qualifications or experience for nurses
wishing to practice in specialized areas or use specific job titles. Nurses
are responsible for understanding and meeting employer requirements.
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All nurses are professionally obliged to ensure they have the knowledge,
skill and judgment to provide safe and competent care. This includes any
education (for instance, certifications or courses) or experience working
with specific client populations. Decisions about Procedures and
Authority outlines these important considerations.
Nurses also are accountable for maintaining and continually improving
their competence. Continuing competence ensures nurses’ performance
ability in a changing health care environment, and contributes to quality
nursing practice and public safety. This accountability is outlined
in Professional Standards, Revised 2002.
Nurses engage in continuing competence by participating in
CNO’s Quality Assurance (QA) Program, for which they are
professionally accountable. Participating in the QA Program helps nurses
engage in practice reflection, goal setting and developing Learning Plans,
all of which help promote and foster lifelong learning. By participating in
QA, nurses demonstrate their commitment to improve their nursing
practice continually.
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o Delegating the Communication of Diagnosis
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Can RNs or RPNs communicate a diagnosis to a patient if the
controlled act is delegated to them?
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Yes, an RN or RPN can communicate a diagnosis if the controlled act is
delegated to them. The nurse (delegate) and physician/NP (delegator)
must meet the requirements outlined in CNO’s Authorizing
Mechanisms practice guideline.
Communicating a diagnosis to a patient has potential risks. In addition to
the appropriate authority, it is important that the nurse has the appropriate
knowledge, skill and judgement to:
Understand the decision-making process leading to the diagnosis including
analysis and interpretation of findings from a variety of sources
Ensure appropriate follow up plans are in place for the patient
Answer questions the patient may have regarding the diagnosis and its
meaning for them. The patient will rely on this information to help them
determine next steps.
Depending on what the diagnosis is, you may need to support the patient
through emotional responses.
If a physician or NP feels that delegating the controlled act of
communicating a diagnosis to a patient or a patient’s representative is
appropriate, they can use their professional judgement to delegate the
activity to an RN or RPN. Before accepting this delegation, the RN or
RPN should consider:
their organization’s policies that support this delegation
the plan for patient follow-up
a communication strategy to inform the delegator of any important
information.
o Immunization Reporting
 I am a registered nurse working in a busy community clinic and often
administer immunizations to clients. I’ve been hearing there are new
and updated reporting requirements under the Health Promotion
Protection Act (HPPA). Is this true?
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Yes. The Health Protection and Promotion Act (HPPA) has been amended
to include reporting requirements for adverse events following
immunizations (AEFIs) and Diseases of Public Health Significance.
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An AEFI is any event or reaction that occurs after receiving a vaccine.
Health care providers must now report AEFIs for all authorized vaccines
in Canada. For an updated list of authorized vaccines and what
information is required in an AEFI report, refer to Ontario Regulation
569.
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The list of Diseases of Public Health Significance (Ontario Regulation
135/18) has been consolidated and updated to reflect current public health
priorities. The list includes all communicable, virulent and diseases of
public health significance that must be reported to the local Medical
Officer of Health.
o Initiating a packing dressing
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As an RN who works in the community, I provide care to an elderly
client recently diagnosed with diabetes. During my last visit, I found a
deep wound on his sacral area. The client has wound care supplies in
his home from when I treated a previous wound. Do I have the
authority to initiate a packing dressing?
An RN would have the authority to independently initiate wound care
below the dermis (including cleansing, packing and dressing) for this
client.
Both RNs and RPNs can initiate some care below the dermis; however,
there are differences in the number of procedures below the dermis that
RNs and RPNs can initiate. Before proceeding, review any relevant
practice-setting policies from your employer that support you in
performing the procedure. You would need to determine if initiating the
procedure is the best course of action for the client.
A nurse must:
 assess the client and identify the problem
 consider all options to address the problem
 address the risks and benefits of each option
 decide on a course of action
 anticipate the management of the outcomes
 accept responsibility for deciding that a particular procedure is
required
 ensure the management of the outcomes
A nurse must also follow the legislation relevant to her or his practice
setting. As a nurse practising in the community, you can initiate according
to the Nursing Act, 1991. (Under the Public Hospitals Act, though, a nurse
practising in a hospital must have an order to perform wound care.)
After treating the wound, you need to put a mechanism in place to manage
the outcomes of the treatment. For instance, you could ask the client to
phone the nursing agency if he notices a change in his sacrum before your
next scheduled visit. You are accountable for the initiation, and for
documenting both the initiation and the outcome in the client record.
o Nurses use of cannabis
 Is it acceptable for nurses to use cannabis?
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Cannabis is legal in Canada for both recreational and medicinal purposes.
While the laws regarding cannabis have changed, nurse’s accountabilities
to provide safe care have not. As self-regulating health care professionals,
nurses are required to ensure their practice and conduct meets the
requirements of the profession and protects the public.
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Mood-altering substances such as cannabis can impair a nurse’s ability to
think clearly, make sound judgments and act decisively. This puts clients
at risk and jeopardizes patient safety. Nurses have a commitment to
patients to practise safely and clients trust that they will not be exposed to
care providers whose abilities may be impaired. 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. A nurse
must use their professional judgment to determine whether using cannabis
medicinally and/or recreationally might compromise their ability to
provide safe care. If you think you may be impaired or affected by any
substance (for example, opiates, alcohol or cannabis) or even illness, you
must refrain from practising. Nurses have an accountability to recognize
their physical and mental limitations, and the impact their own health and
well-being has on their ability to provide safe, effective and ethical care.
This accountability is outlined in Ethics practice standard and
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 your employer when you
believe another nurse or health care provider may be impaired. This
accountability is outlined in the Professional Standards, Revised
2002, Ethics and Therapeutic Nurse-Client Relationship, Revised
2006 practice standards.
o Nursing Assessments
 Can RPNs conduct a nursing assessment and develop plans of care for
patients, or can this only be done by a RN?
 Regardless of a nurse’s category of registration, completing a nursing
assessment is a foundational competency for all nurses. These are outlined
in the Entry-to-Practice Competencies.
 Nurses are expected to use their clinical judgement to determine whether
they can safely and competently complete and assessment and provide
care to a specific patient. Nurses are also expected to seek help, and to
refrain from performing any activity that they are not competent to
perform. Nurses may acquire specialized knowledge and this would
influence which patients they are best suited to work with.
 Employers and nurses have a shared responsibility to create environments
that support quality practice. Nurses must ensure they are aware of their
employer policies that support nursing assessment. If employer do not
have policies that are in their patient’s best interest and safety, nurses
should advocate for clear policies.
 Is a medical directive required for vital signs?
 Nurses can perform physical assessments such as vital signs without an
authorizing mechanism (direct order or directive), as this is part of nursing
assessment. Though nurses may not require an authorizing mechanism to
perform this activity, employer policies may provide specific direction
related to which category of nurse can perform this activity and how
frequently.
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Regardless of an employer’s policy, nurses are accountable for ensuring
they use appropriate knowledge, skill and judgment when assessing and
reassessing the health needs of patients. This includes having appropriate
knowledge in the performance of clinical skills, such as assessing vital
signs.
o Pt- centred care
 How do I improve a patient’s experience in my practice?
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Asking yourself, “What’s best for the patient?” and involving the patient
in their care needs is a key part of improving their experience.
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Patient-centred care is an essential component of health care. In patientcentred care, nurses consider patients’ individual needs and preferences,
and ensure patients are active participants in all aspects of their health care
decisions.
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While it is up to the patient to determine what course of action they will
take, it’s critical the patient is fully informed and understands the
procedures or care they are about to receive.
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Nurses help patients by providing clear and timely information and talking
to them in ways they understand. If a patient doesn’t understand what is
happening, or is uncertain or unhappy with the care they are receiving,
nurses respond by working with patients to resolve their concerns.
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There may be occasions where there are delays or gaps affecting patient
care. When this happens, it is important for nurses to explain the reasons
for these delays.
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When nurses keep patients at the centre of their health care journey and
support them at every step of the way, the therapeutic nurse-patient
relationship benefits. There is also a lasting positive outcome on their
patient experience.
o Performing frequent client assessments
 I’m a nurse on an in-patient mental health unit. We often receive
orders from physicians asking us to perform checks on patients every
15 minutes due to a high risk of self-harm. These 15-minute checks
are difficult for the nurses to perform because of our high workload
and nurse-to-client ratios. What are our accountabilities for frequent
assessment and monitoring?
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Performing ongoing client assessments is critical to providing safe client
care. Assessment is a professional accountability and an essential part of
your nursing practice, as outlined in Professional Standards, Revised
2002.
All nurses are expected to regularly assess clients, although certain clients
may require more frequent assessments, such as monitoring every 15
minutes. For example, if you work with clients who have acute mental
illnesses, frequent checks may be ordered because there are unique safety
issues. These include an increased risk of violence, self-harm and suicide.
Many of these clients may be isolated, require restraints or have limited
capacity for advocating for themselves. Therefore, frequent monitoring is
essential in supporting client safety.
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Professional Standards states that nurses must facilitate, advocate and
promote the best possible care for clients. Nurses must also take action if
client safety and well-being are compromised. Therefore, if nurses have
concerns about their ability to perform ongoing assessments as ordered
and part of the client’s care plan, nurses are accountable for sharing those
concerns with their team and clinical manager.
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All members of the health care team have a shared accountability to
advocate for quality practice environments and support systems that
promote safe care. Nurses are also accountable for providing a complete
record of client care including documenting assessment data such as when
client assessments are completed. For more information about these
accountabilities, see the Documentation, Revised 2008 practice standard.
o Refusing an Assignment/ discontinuing service
 As nurses, your primary accountability is to patients. When deciding
whether to provide care in a particular situation, exercise your professional
judgment and follow an ethical decision-making process.
 Abandonment occurs when a nurse accepts an assignment and
discontinues care, without:
 the patient requesting the discontinuation
 arranging a suitable alternative or replacement service; or
 allowing a reasonable opportunity for alternative or replacement services
to be provided
 Nurses may be concerned that declining work could be considered
abandonment. There are many situations that can lead nurses to think
about refusing assignments or discontinue care. For example, working in
practice environments outside of their knowledge, skill and judgement,
workload issues or even workplace strikes.
 When deciding whether to refuse an assignment or discontinue nursing
care, you are accountable to:
 Assess the potential for harm to yourself and your patients
Consider the circumstances of the situation and your practice
setting. Continue to work within your knowledge, skill and
judgement and complete a point-of-care risk assessment.

Use evidence-based sources to inform your decision-making
and consider the context of the situation

Communicate your concerns to your employer
Tell your employer that you are considering refusing an
assignment or discontinuing nursing care. Discuss your concerns
with your employer and consider their response. If, after doing so,
you choose to refuse the assignment or discontinue care, work with
your employer to develop a plan to ensure that safe patient care
continues.

Ensure your patient(s) continue to receive care
You must ensure that a suitable alternative for care is available for
your patient(s) or allow reasonable time for alternate or
replacement services to be arranged.

Document your decision-making process, actions and decision
o Sleeping during shift breaks
 I have just started working on a medical/surgical unit in an acute care
hospital. During breaks, it is common for nurses to go to the lounge
and sleep. Sometimes, I have to wake them up to return to duty. I’m
uncomfortable with this practice, but my colleagues tell me that they
can do what they like on their breaks. How should I handle this
situation?
 A nurse’s primary responsibility is to her or his clients. Because of this,
deciding what to do on a break is influenced by many factors. The most
important of these factors are the needs and safety of the client, the
adequacy of staffing and the potential for sudden changes in client care
needs.
 Clarifying employer expectations is important in identifying whether
sleeping during breaks is an accepted practice in your workplace. You
could also consult your collective agreement to see if it discusses break
activities.
 Other questions related to sleeping during breaks may include:
 Do I feel refreshed or drowsy after sleeping?
 Does this interfere with my ability to provide care?
 Am I accessible to colleagues if they need assistance during my break
(i.e., can they find me and wake me up)?
 Because the nurse also has a responsibility to contribute to positive team
functioning and to support colleagues, it may be helpful to tell your

colleagues about the discomfort you experience when you must wake
them. See what other strategies could be identified.
The information on this page can be used to initiate discussion with your
colleagues. It may also be helpful to involve your health and safety
committee or professional practice leader.
o Risking fatigue with long hours
 I recently read about the increased risk of errors associated with
medical residents working long hours. I think this is potentially an
issue for nurses as well. Does CNO specify the maximum number of
hours a nurse can work? Is there a plan to legislate the hours a nurse
can work?
 No, CNO doesn’t specify the maximum number of hours a nurse can
work, nor are there plans to legislate this. Nurses are expected to use
professional judgment to determine whether fatigue might interfere with
their performance and, if so, to refrain from practising. This is similar to
nurses’ accountability to refrain from practising when their ability is
affected by a substance (for example, pain medications, alcohol) or illness.
Each nurse’s tolerance for fatigue is individual. For this reason, each nurse
needs to assess if her/his ability is compromised and, if so, to take
appropriate action.
 Fatigue can impair the ability to think clearly, make sound judgments and
act decisively. While it is the nurse’s and employer’s responsibility to find
the right balance between work and time off, only the nurse can determine
her or his tolerance level for stress, anxiety and fatigue.
 CNO encourages nurses who find themselves in situations where they or
their colleagues are working while fatigued to take action. Nurses should
discuss their concerns with their managers/supervisors, including the
impact on client care and safety, and explore possible solutions. Nurses in
administrative roles are accountable for ensuring that mechanisms allow
for staffing decisions that are in the best interest of clients and professional
practice. Working together, nurses and employers can discuss staffing
issues and identify innovative and creative solutions.
 When deciding to work overtime, accountability and commitment need to
be weighed carefully against the degree of fatigue that the nurse is
experiencing. Although nurses may want to accept extra shifts to help
short-staffed colleagues or to earn extra money, their first priority is to
assess their ability to continue to provide quality care. It is acceptable to
work overtime only when they feel competent to provide safe and ethical
care.
o What info is required on nametags?
 I am a nurse working on a mental health in-patient unit. Our
employer has a policy where employees have to wear name tags
stating full names. My colleagues and I are uncomfortable with this




practice because of personal safety concerns. What are our
accountabilities as nurses to disclose our full name to patients?
Nurses are accountable for identifying themselves to patients. You should
always introduce yourself using your first name, last name, title and role in
the patient’s care.
CNO recommends that a nurse’s name tag include the first name, last
name and category of registration. Patients are entitled to know the names
of nurses who provide them with health care services. Identification of a
nurse allows patients to hold the nurse accountable for their professional
conduct.
Some practice settings may choose not to display a nurse’s full name on
name tags. However, nurses should not expect to be able to maintain
anonymity and must remain accountable for identifying themselves to
their patients.
A nurse who has reasonable grounds to be concerned for their safety and
well-being when disclosing their full name is encouraged to work with
their employer who is responsible to help protect the nurse against
workplace violence and harassment.
o Witnessing Abuse
 I witnessed a nursing colleague hitting a client. I intervened and
stopped the abuse. When I questioned my colleague, she told me she
was tired and frustrated but it will never happen again. She then
asked me not to tell our manager. What is my responsibility in this
situation?
 You are responsible for protecting the client by reporting the physical
abuse to the appropriate authority in your organization. Nurses protect
clients from harm by ensuring abuse is prevented or stopped, and reported.
If a nurse witnesses any member of the health care team abusing a client,
then the nurse must intervene immediately and take action by reporting the
event to the employer or authority responsible for the health care provider.
A nurse must also inform the client of their right to contact the police and
CNO.
o Administering the Influenza Vaccine

I have recently received a job offer to work in a community clinic
administering influenza vaccines and other vaccinations. What should
I consider before accepting this position?

Here’s what you need to consider when informing your decision to accept
this role:

AUTHORITY





The Medication practice standard states that nurses must ensure
they have the knowledge, skill and judgment needed to perform
medication practices safely. Nurses are accountable for
determining their individual learning needs and what best helps
them achieve their objectives.
Consider your competence to perform the activity.
SAFETY



Consider who will provide you with an order or directive to
perform the controlled act.
COMPETENCE


Administering influenza and other vaccines involves the controlled
act of administering a substance by injection. Though this
controlled act is authorized to all nurses, RNs and RPNs require
an authorizing mechanism, such as an order or directive, to
perform it.
RNs and RPNs can only accept an authorizing mechanism for a
controlled act from a physician, dentist, chiropodist, midwife or a
NP. For information related to the COVID-19 vaccine, please see
our COVID-19 webpage.
Nurses maintain patients’ trust by providing safe and competent
care. This includes promoting safe care and contributing to a safe
culture within their practice environments, when involved
in medication practices. Patient safety is a shared responsibility
between nurses and their employers.
Consider how you will ensure safe patient care in your practice
environment.
DOCUMENTATION

Nursing documentation, is an important component of nursing
practice and the interprofessional documentation that occurs within
the patient’s health record. Nurses ensure that documentation
presents an accurate, clear and comprehensive picture of the
patient’s needs, the nurse’s interventions and the patient’s
outcomes.
o Authority in initiate IV lines

I’m an RN practising at a wellness clinic where naturopaths offer
clients intravenous (IV) chelation therapy. The clinic protocol is for
the RN to start the IV and then the naturopath administers the
chelation treatment but there is no order in place for a nurse to insert
IVs. As an RN, am I permitted to initiate an IV for this therapy?

No, you are not permitted to initiate the insertion of an IV in this situation.

Initiation means a nurse independently decides that a controlled act
procedure is required and then performs the procedure without an order.
The Authorizing Mechanisms practice guideline lists the procedures that
RNs and RPNs can initiate, and outlines the conditions necessary for
initiating them.
RNs have the authority to initiate venipuncture to establish peripheral
venous access and maintain patency (0.9% NaCl only) when a client
requires medical attention and delaying venipuncture is likely to be
harmful. Inserting an IV for chelation therapy at the wellness clinic does
not fit this description.


Because you cannot initiate the insertion of the IV in this situation, you
will need an order to perform it. The order cannot come from a naturopath.
The Nursing Act, 1991 lists the practitioners from whom nurses can accept
orders for controlled acts; naturopaths are not included on this list.

To facilitate the authority for IV insertion, the wellness clinic team
members could work together to create a directive that is authorized by an
NP or a physician. For more information on directives, read
the Authorizing Mechanisms and Directives practice guidelines.
o Difference between directive and prescription
 Is implementing a directive the same as prescribing?

No. Implementing a directive and prescribing are different.

Prescribing is the act of writing an order for a procedure, treatment, drug
or intervention. Prescribing applies to an individual patient. The person
who writes the prescription/order is accountable.

A directive is a type of written order given to a nurse to perform an
activity or procedure. Directives are intended for multiple patients when
specific conditions are met and certain circumstances exist. For example,
mass vaccination clinics. Nurses are accountable for their decision to
implement the directive.

Nurses who implement directives are accountable for ensuring that they
understand the directive. They must make sure the directive contains all of
the information they need to carry out the order safely. They must also
determine if it is an appropriate order by considering the patient, the
activity/procedure and the environment. Additionally, nurses must make
sure they have the knowledge, skill and judgement to perform the activity.

It is also important to have organizational policies in place that clearly
outline how to identify the physician or NP responsible for the care of the
patient so they can be contacted with questions or to clarify the order for
their patient
o Communicating Directives






I am a public health nurse working in a sexual health clinic. The
clinic’s physician has written a medical directive which allows myself
and the other nurses to provide contraception to clients. One of my
clients wants to pick up her birth control pills at her pharmacy
instead of our clinic. Under the directive, can I communicate the
order to an external pharmacist to dispense the prescription to the
client?
Yes, you can. Nurses and pharmacists who implement directives are
not prescribing the medication, rather they are using the directive to
provide medication to clients, provided the conditions and circumstances
outlined in the directive have been met. It is your responsibility to ensure
the directive is clear, complete and appropriate, as outlined in
the Medication practice standard.
In this scenario you have the appropriate authorizing mechanism in place
to implement the client’s treatment plan. The medical directive is the order
for dispensing. This means to select, prepare and transfer stock
medication for one or more prescribed medication dose to a client or the
client’s representative for administration at a later time.
It is your responsibility to assess the client to make sure she meets the
conditions outlined in the directive. If the conditions are met, you can
request the pharmacist to dispense the medication to the client.
What should I consider before contacting the pharmacist?
Before you contact the pharmacy, review your organization’s policies on
communicating prescriptions to pharmacists. These policies usually
include procedures to make sure all information remains confidential,
there is no miscommunication and the medications are safely dispensed. If
your workplace doesn’t have any policies, we encourage you to work with
your employer and other members of the healthcare team to help develop
policies and procedures that support:




Confidentiality and privacy,
Safe dispensing of medications,
Clear, effective communication, and
Timely access to care.
o Do directives expire?
 NO does not specify the length of time that directives can be in effect.
When the evidence, laws or CNO standards change, you should consider
whether a directive needs to be reviewed.

The practitioner who authorized a directive, or an organization where a
directive is implemented, may have set an expiry (or review date) for the
directive. If this is the case, then you should consult with whoever set the
expiry or review date if you have questions about it.

If you think a directive is no longer valid, follow up with an ordering
practitioner for clarity about applying the directive. You could also work
with your organization to develop a process for revising directives so they
reflect changes to clinical evidence, regulation or CNO standards.
o Signing for narcotic wastage


CNO does not restrict nurses from signing as a witness for narcotic waste
by another nurse when their employer’s policy requires it. CNO does not
require nurses to document the witnessing of narcotic wastage but it may
be required by organizational policy or relevant practice setting
legislation.
To increase clarity, an employer’s policy could identify what the signature
of the witness represents, and all accountabilities of the witness.
o Signing prescriptions with “as per…”

I’m an RN working in a family physician’s office. The other day, Dr.
Smith asked me to write a new prescription for a client on her behalf
because she was busy with another client. She instructed me to write
the prescription and sign my name followed by, “as per Dr. Smith.”
Can I do this?

No, you cannot sign the prescription as the physician requested. Even if
you write “as per Dr. Smith,” signing your name would mean you
authorized the prescription. RNs and RPNs do not have the authority to do
this.

Since Dr. Smith was physically present in the office to instruct you, the
safest practice would be for her to personally write and sign the
prescription. Then, you could either give the prescription to the client or
fax it to the client’s pharmacy through a secure fax line.

Furthermore, Dr. Smith’s instruction is a verbal order which is not
appropriate in this situation. Verbal orders are only allowed in emergency
situations or when the prescriber is unable to document the order. (For
more information on verbal orders, read the Authorizing
Mechanisms practice standard.)
o Accessing client health records
 You can only access a client’s health records in order to provide health
care or to assist in providing health care to the client. No matter what your
nursing role is, it is not appropriate to access a chart because you think it
has educational value or you are curious about a particular clinical case.
This is according to legislation, such as the Personal Health Information
Protection Act, and CNO standards.

Personal health information belongs to the client. You have a
responsibility to maintain the confidentiality and privacy of a client’s
personal health information. When caring for a client, you’re expected to
obtain the client’s consent before collecting, using or disclosing their
information outside the health team or circle of care.

Respecting a client’s privacy and keeping their information secure and
confidential is critical for establishing trust with them. Trust is essential
when establishing and maintaining the nurse-client relationship because,
as a client, they are in a vulnerable position. As well, when a client trusts
the nurses in their circle of care, it builds respect for the nursing
profession. Confidentiality and privacy breaches may cause clients to
mistrust the nurses caring for them and negatively affect the nurse-client
relationship.

Often, the circle of care can include many health care providers. There are
some specific nursing roles where it is inappropriate to access personal
health information, even if you are in the circle of care. To learn more,
read the Ontario Privacy Commissioner’s Circle of Care: Sharing
Personal Health Information for Health-Care Purposes.
o Police access to health information
 My hospital has developed a new procedure that allows police to
complete a form to request personal health information about clients
who come to our emergency department. Can police access this
information without a warrant or subpoena?

Yes, under certain circumstances the police can access this information.

The Personal Health Information Protection Act, 2004 (PHIPA) permits
hospitals to develop a procedure for releasing information to the police.
By creating such a procedure, your hospital has formalized the process for
giving information to the police during an investigation.

The responsibility for the decision to disclose information requested by
police lies with the hospital. As an employee of the hospital, you are not
breaching CNO practice standards if the hospital's procedure complies
with PHIPA and you are asked by the facility to provide personal health
information to police.

Your hospital's procedure for police accessing information should include
criteria regarding the circumstances under which the information is
provided. For example, the police need to demonstrate that the request is
urgent. In addition, the hospital needs to appoint a decision-maker to
handle urgent requests from police, and this person needs to be clearly
identified in the policy.

The designated decision-maker does not need a client's consent to disclose
health information to the police, but must ensure that the information that
he or she supplies complies with PHIPA. Of course, this procedure is
unnecessary if the police provide a warrant or subpoena.
o Mandatory reporting of a gunshot wound
 The Mandatory Gunshot Wounds Reporting Act, 2005 requires hospitals
and other prescribed health care facilities to report to police, as soon as is
practical, the following information about an individual with a gunshot
wound:
 the name of the client, if known; and
 the location of the reporting facility.
 The legislation does not indicate who is responsible for reporting the
information. Refer to your facility's and/or unit policy for who on the team
is responsible for reporting the information. You may want to refer to your
facility's policies for other legal reporting obligations, such as those for
suspected child abuse, to determine how nurses have met reporting
obligations while maintaining therapeutic relationships with their clients.
o OHNs and confidentiality
 I'm an occupational health nurse (OHN) in a small community
hospital. I'm frequently asked by my manager to allow staff from
human resources, other managers and/or corporate lawyers access to
employee files as they do not understand my obligation to maintain
confidentiality of the client's chart. How should I handle such
requests?
 While conflict between your commitment to your employer and to your
client is difficult, you have an ethical, statutory and professional obligation
to maintain the confidentiality of information obtained through the nurseclient relationship. An employee who receives care from an OHN is the
nurse's client. Sharing the client's information without his/her consent or
the consent of his/her legal representative is a breach of confidentiality.
 This obligation is clearly stated in the CNO’s Ethics practice document:
 Confidentiality involves keeping personal information private. All
information relating to the physical, psychological and social health of
clients is confidential, as is any information collected during the course of
providing nursing services.
 As well, section 1(10) of Ontario Regulation 799/93 under the Nursing
Act, 1991 states that is it professional misconduct to give:
 Information about a client to a person other than the client or his or her
authorized representative except with the consent of the client or his or
her authorized representative or as required or allowed by law.
 While in law, records kept in the course of a business are owned by the
business, this refers to owning the actual paper or computer. It does not
entitle the employer access to the client's health information. In order for
these individuals to gain access they would need to provide you with
consent from the client, a court order or a subpoena.
o Discussing clients with colleagues online

Lately, some of my colleagues have been gossiping about clients and
co-workers on Facebook and other social-networking websites. Are
they allowed to do this?

Discussing clients on websites such as Facebook is a breach of client
confidentiality. Nurses are expected to keep health information that a
client discloses confidential. It should only be shared with other health
care providers directly involved in the client’s care and with others whom
the client consents to share information.

Generally, if certain ways of referring to clients and colleagues are
inappropriate in the practice setting, they are inappropriate in the public
sphere, including the internet. Anyone with a computer and internet
connection can access Facebook and other social networking sites. Airing
grievances about co-workers and complaining about workplace issues in
these public forums does little to constructively resolve conflict. In fact,
such actions could exacerbate conflict. As professionals, nurses are
expected to address work concerns with the appropriate authority (e.g., a
manager).

Nurses also need to determine if their employer has a policy that includes
guidelines on what is acceptable for staff to discuss on social-networking
sites.

While CNO rarely turns its attention to member behaviour outside the
practice setting, it may intervene when a nurse’s conduct outside of the
workplace creates issues with their practice. Nurses are responsible for
advocating for the profession and maintaining an appropriate image of
nursing. The public holds nurses to high standards of behaviour. What a
nurse does outside of the practice setting can affect how she or he is
perceived professionally.
o Withholding info/ lockbox provision

My client doesn’t want to share part of his personal health
information with the other members of the health care team. Am I
required to keep this information from my team?

Yes, you must withhold the information from the health care team. The
client has the right to refuse to share part of his personal health
information with other health care providers. This right is referred to as
the lockbox provision.

However, you can still examine the implications of this choice with him.
By discussing the possible consequences of not releasing the information,
you will help the client make an informed decision.

If a client instructs a nurse not to release a part of his or her health
information to another practitioner, the nurse must tell the other
practitioner that some relevant information has been withheld at the
direction of the client.

Check if your organization has a policy for documenting locked
information. If there isn’t one, you may advocate for a policy that explains
the documentation process.
o Obtaining informed consent
 CNO believes that whoever requires the informed consent should also
obtain the patient's signature. Some employers, however, require nurses to
obtain the patient's signature on consent forms as part of their role.
 The most important part of the consent process is informing the patient
about the proposed treatment and what to expect. This includes informing
the patient about:
 the nature of the treatment,
 risks and side effects of the treatment
 alternative courses of action
 potential consequences of not having the treatment
 Patients also should have the opportunity to ask and receive answers to
questions they have about the treatment.
 A patient's signature is meaningless if the patient is not informed. Nurses
are often told that when they obtain a patient's signature on a consent
form, they are only witnessing the signature and not verifying that
informed consent was obtained. However, nurses have ethical and
professional accountabilities to ensure the patient is fully informed and
capable of giving consent.
 Nurses should ask patients if they understand what it is they are
consenting to and if their questions about the proposed treatment have
been answered. If the nurse believes the patient has less than a full
understanding of the proposed treatment, the nurse must act as a patient
advocate to ensure the patient receives the necessary information.
 Nurses' accountabilities exist regardless of employer policies about the
role of the witness.
o Performing laser therapy

There are many different forms of energy that are not listed as controlled
acts in the Regulated Health Professions Act, 1991 (RHPA). In instances
where a specific form of energy is not listed in legislation, the RHPA does
not restrict how or by whom that form of energy may be applied.

The forms of energy mentioned by name in the RHPA include electricity,
electromagnetism and soundwaves. The legislation does not refer to laser
therapy; therefore, the administration of laser therapy is not restricted and
a nurse can administer it to clients.

It is important to remember that controlled acts are not the only procedures
that could potentially cause harm, and that having the authority to perform
an activity does not necessarily mean it is appropriate to do so. Nurses
performing laser therapy should be aware that all practice standards would
apply just as they would with any other procedure.

When performing a procedure of any kind, nurses must ensure they have
the required knowledge, skill and judgment to perform the procedure
safely and ethically, as well as manage outcomes. They also need to
ensure they have the authority to perform the procedure by way of an
authorizing mechanism (e.g., orders, initiation, directives and delegation).

What is a form of energy?

There are 14 controlled acts listed in the RHPA, including: “applying or
ordering the application of a form of energy prescribed by the regulations
under this Act.”

The regulation under this Act that refers to controlled acts identifies the
forms of energy as such:


1. Electricity for,
i. aversive conditioning,
ii. cardiac pacemaker therapy,
iii. cardioversion,
iv. defibrillation,
v. electrocoagulation,
vi. electroconvulsive shock therapy,
vii. electromyography,
viii. fulguration,
ix. nerve conduction studies, or
x. transcutaneous cardiac pacing.
2. Electromagnetism for magnetic resonance
imaging.
3. Soundwaves for,
i. diagnostic ultrasound, or
ii. lithotripsy.
This list is inclusive of all forms of energy that fall under the controlled
act related to applying or ordering the application of a form of energy. If
an intervention or test is not listed in this regulation, then it is not
considered a form of energy according to the regulation, and therefore not
considered a controlled act.
o Bladder Scanning
 Are nurses permitted to perform portable bladder ultrasound
scanning as part of an assessment?
 Yes. Portable bladder ultrasound scanning falls within the scope of
nursing practice when it is used as part of a routine nursing assessment.
For example, to determine urinary retention and the need for urinary
catheterization.

Before performing this procedure, you must determine that you are
competent to do so and can interpret the findings. You will also need the
knowledge, skill and judgment to determine the procedure is appropriate,
manage the client during the procedure and provide follow-up care.

o Delegation



What is delegation?
 Delegation is a process by which a health care professional who
has legal authority to perform a controlled act transfers that
authority to an unauthorized person.
 There are 14 controlled acts in the Regulated Health Professions
Act, 1991 (RHPA). By definition, a controlled act can cause harm
if it is performed by an individual who is not competent. To learn
more about controlled acts, see RHPA: Scope of Practice,
Controlled Acts Model.
What are some common examples of delegation?
 A nurse who works in the community can delegate the
administration of heparin by injection to an unregulated care
provider who is providing care in the patient’s home. In this
example, the nurse is delegating the controlled act of
“administering a substance by injection.”
 In another example, a nurse who provides home care to a patient
requiring dressing changes for a wound extending below the
dermis can delegate the controlled act to the patient’s spouse. In
this instance, the nurse is delegating the controlled act of
“performing a procedure below the dermis.”
 Also, a nurse may accept the authority to defibrillate through
delegation from a physician. Defibrillation falls under the
controlled act of “applying a form of energy."
What do I need to know about the delegation regulation?
 The regulation sets out the:
 categories and classes of nurses who can delegate (for example,
RNs and RPNs in the general class and NPs)
 requirements to delegate and to accept delegation (for example,
considering the best interests of the client), and
 requirements for documenting the delegation.
 Nurses can only delegate controlled acts that they are trained or
competent to perform. The regulation also prohibits delegating
certain controlled acts (for example, NPs cannot delegate setting a
fracture).
 Sub-delegation is prohibited. Sub-delegation occurs when an
individual who accepts a delegation then delegates the same act to
another person. This is not allowed because the individual who is
sub-delegating does not have legal authority to perform the act.




Where can I find the requirements for delegating or accepting
delegation?
 CNO’s Authorizing Mechanisms practice guidelinelists the 10
requirements nurses must meet when delegating to others. It also
lists the 7 requirements nurses must meet when accepting
delegation.
How do orders and delegation differ?
 Delegation and orders are two different authorities.
 Delegation provides the legal authority to perform a controlled act.
An order outlines how to perform that controlled act.
 Refer to CNO’s Authorizing Mechanisms to learn more about
orders.
 If a nurse receives an order for a controlled act procedure that they
already have authority to perform through the Nursing Act,
1991 (for example, the administration of a substance by injection),
the nurse does not need delegation.
 If the nurse receives an order for a controlled act procedure for
which they are not authorized to perform (for example, managing a
labour or conducting the delivery of a baby), then the nurse needs
delegation from an authorized individual, such as a physician, as
well as an order for the procedure.
Can someone who does not have authority to delegate a controlled act
teach a nurse how to perform the procedure?
 Yes. Teaching may be part of the delegation process but it is not
equivalent to delegating.
 For example, a nurse educator with the appropriate knowledge,
skill, and judgement may teach a group of nurses how to adjust a
pacemaker. Following the education session, the nurses will have
the competence but they will not have the authority to perform the
controlled act until it is delegated by an authorized practitioner,
such as a physician.
 A number of requirements need to be met to ensure the delegated
procedure is performed safely. One of the requirements is being
satisfied that the delegatee has the knowledge, skill and judgment.
One of the ways to ensure this is through teaching.
Who can delegate, which acts can be delegated and who can accept
delegation?
 RNs and RPNs can delegate and accept delegation if they are
registered in the General, Extended or Emergency Assignment
Class. RNs and RPNs cannot delegate the controlled act of
dispensing a drug or treating, by means of psychotherapy
technique.
 NPs cannot delegate the following controlled acts:
 prescribing, dispensing, selling or compounding medication
 ordering the application of a form of energy
 setting a fracture or joint dislocation



treating by means of psychotherapy technique
Nurses in the Temporary Class cannot delegate or accept
delegation. Nurses in the Special Assignment Class cannot
delegate the authority to perform controlled acts to others, but may
accept delegation.
Nurses are accountable for ensuring that delegation is supported by
setting specific legislation, for example Fixing Long-Term Care
Homes Act or your employer policies.
o Ultrasound in nursing assessment
 For years, CNO communicated that RNs and RPNs could apply ultrasound
when performing a nursing assessment. This is how we interpreted the
term “diagnostic ultrasound,” which is used in law.
 During a recent conversation with the Ministry of Health and Long-Term
Care, we learned that our interpretation of “diagnostic ultrasound” was
incorrect. In fact, any ultrasound that produces data or an image,
regardless of whether it is used for diagnosis, is “diagnostic ultrasound”.
 Since then, we have been working with government to amend the law so
current appropriate use of ultrasound can continue. The change ensures
that client care is not impacted.
 The law now states that all nurses in a therapeutic nurse-client relationship
can apply ultrasound to conduct routine nursing assessments to help
develop or implement the client plan of care.
 In the course of applying ultrasound, nurses are accountable to
expectations in the practice standards including Decisions About
Procedures and Authority. This requires nurses to:
 have sufficient knowledge, skill and judgment to determine the
appropriateness of performing the procedure
 seek consultation when the limits of knowledge, skill and judgment have
been reached
 determine whether the management of the possible outcomes is within
her/his knowledge, skill, judgment and authority
o Accountability in ultrasound

The Decisions About Procedures and Authority practice standard has a
number of expectations for all nurse when applying ultrasound. These
include:

having sufficient knowledge, skill and judgment to determine the
appropriateness of performing the procedure

ensuring the rationale for performing the procedure is based on
achieving the best outcomes for the client

identifying the required resources (present and future) to manage
outcomes before performing a procedure

applying best judgment and appropriate authority to make and act
on decisions during the procedure

ensuring the physical environment and access to equipment and
other resources supports nurses in safely performing procedures
o Authority to use AEDs
 The use of this device falls under a controlled act (“applying or ordering
the application of a form of energy”) in the Regulated Health Professions
Act, 1991. It is not one of the controlled acts authorized to all nurses.
 However, nurses may perform the act of applying a form of energy in one
of two scenarios:
 Through delegation: when someone authorized to perform the act can
transfer the authority to a nurse or nurses through a delegation process or
 Through the emergency exemption: when providing first aid or
temporary assistance during an emergency.
 The nature of the practice environment determines which option is the
most appropriate. Whether the emergency exemption applies depends on
the characteristics and the needs of the client(s), the expected occurrence
of unpredictable events, and the types of services that the setting provides.
Whoever has the decision-making authority within the practice
environment must identify which option is appropriate.
 If the emergency exemption does not apply, the nurse would require
delegation and an order to apply the AED. For more information about the
requirements for accepting delegation please see our Authorizing
Mechanisms document. An order can be either a direct order or a directive.
As with any procedure, having the proper authorizing mechanism in place
does not mean it is always appropriate to perform the procedure.
 Whichever option is chosen, nurses are held to the same expectations
when applying an AED as they are when performing any procedure. These
expectations include:
 Nurses are accountable for the decision to perform the controlled act and
for its performance.
 Nurses must consider the client’s needs and best interests, and determine
whether the client’s condition warrants the performance of the procedure.
 Nurses must have the knowledge, skill and judgment to perform the
procedure safely, effectively and ethically.
 Nurses need to ensure that the practice environment has the appropriate
resources to perform the procedure safely and manage reasonably

expected outcomes. (For example, a nurse must consider that defibrillation
is only one component in the continuum of care required during a cardiac
arrest.)
Nurses are accountable for participating in all aspects of the assessment
and management of the procedure and its outcomes. They are also
responsible for documenting this information.
o Medical Leave and non-practising class

It depends on how long you have not been practising nursing. If you have
not practised nursing at any time in the previous three years you
are required to apply to register in the Non-Practising Class or resign
from CNO.

This contributes to public protection by ensuring that members registered
in the General or Extended classes have recent nursing practice.

If you remain employed while on an extended medical leave, CNO doesn’t
recognize this as evidence of practice.
o Electronic signature
 The information technology professionals who installed and support your
new system should be able to inform you about the security of the system
and confirm whether only the authorized user has access to his/her
electronic signature.
 If you are aware that an electronic signature is being used without
authorization, report this to the contact person in your practice setting.
 Health care professionals can protect the integrity of their electronic
signatures by:
 maintaining the confidentiality of passwords or other access information;
 changing their password as per facility policy or more frequently if
security is at risk;
 using passwords that are not easily deciphered;
 logging off when not using the system or when leaving the
terminal;
 ensuring that the keyboard and monitor are placed to ensure
maximum privacy and confidentiality; and
 advocating for appropriate education and technical support.
o Pronouncing Death
 While no legal requirement prevents an RN or RPN from pronouncing
death, there is a distinction between pronouncing death and certifying
death. For clarification on the difference, review the definitions by
the Canadian Medical Protective Association.

Unless you are a RN employed by the Office of the Chief Coroner (OCC)
as a Coroner Investigator, RNs do not have the authority to sign Medical
Certificates of Death (MCODs).
o Accepting gifts
 To maintain appropriate professional boundaries in your therapeutic
relationship with the client, you should not accept the gift.
o Caring for a friend
 The nurse should not be assigned to care for her friend or family member
unless there is no other care provider available. You can read more about
this in the Therapeutic Nurse-Client Relationship practice standard (page
17).
o Protecting Patients Act, 2017
 How does the Protecting Patients Act, 2017 (Bill 87) affect me in my
practice?
 The Protecting Patients Act, 2017 (Bill 87) is an important piece of
legislation that strengthens the protection of, and response to patient
sexual abuse by health professionals. Bill 87 introduces significant
changes to the Regulated Health Professions Act, 1991 (RHPA),
including:
 Definition of patient: Within the context of sexual abuse, an individual is
considered to be a “patient” for a period of one year following the end of
the therapeutic nurse-client relationship. This means that any sexual
contact between a nurse and a patient or former patient within the one-year
time frame is sexual abuse. It does not matter if the patient consented to
the sexual acts.
 Additional information on the public register (Find a Nurse): The College
of Nurses of Ontario (CNO) already posts on the public register most of
what is required in Bill 87. Additional information to be posted on the
public register will now include the self-reporting of all professional
licenses and registrations in any jurisdiction.
 Funding eligibility for therapy and counselling for victims of sexual abuse:
Patients can immediately apply for funding for therapy and counselling as
soon as a complaint of sexual abuse is filed.
 An expanded list of sexual abuse acts and other conduct resulting in
mandatory revocation: Prior to the amendments made by the Bill 87, the
RHPA provided a list of sexual acts resulting in mandatory revocation of a
member’s certificate of registration. This list has been expanded as a result
of the new changes to Bill 87.
o Providing care to a sexual partner
 In some instances, nurses, especially those working in small communities,
may be required to care for a family member, friend or acquaintance. If a
nurse’s current or previous sexual partner is admitted to an agency where
the nurse is providing care or services, the nurse must make every effort to
ensure that alternative care arrangements are made. Until alternative
arrangements are made, however, the nurse may provide care.
o When apt attempts sexual touching
 Nurses are encouraged to review and follow their employer policies
related to reporting patients’ attempts of sexual touching. Under
the Occupational Health and Safety Act, employers are accountable for
establishing a safe work environment and minimizing real or potential
risks to employees and patients alike. CNO encourages nurses to work
collaboratively with their employers to appreciate real or potential
threats, review relevant organizational policies, and if needed, develop
policies and guidelines that are specific to the practice setting and
driven by safety.
 With respect to the scenario in this question, nurses should tell the
patient it is inappropriate to touch them in a sexual way. Nurses should
document the interaction and ensure their manager is aware.
 Here are some guiding questions to consider as you reflect on this
inquiry:

What does your organizational policy state about this?

Has your health care team experienced similar situations in the
past?

If so, how was the situation managed?

How have other care delivery teams managed similar practice
issues?

Have I consulted with my union (if applicable)?
o Administering Botox
 Yes, you may administer botulinum toxin if there is an appropriate order
in place. Administering botulinum toxin falls under the controlled act of
administering a substance by injection. This is one of the controlled acts
that RNs and RPNs are allowed to perform with an order from an
authorized health care professional, such as a NP or physician.
o Administering methadone
 Under the Controlled Drugs and Substances Act, 1996 and the
associated Narcotic Control Regulation, pharmacists are permitted to
provide methadone to a hospital employee or a practitioner in a hospital.
Therefore, under the legislation, nurses, as employees in a hospital, are
permitted to administer methadone with an order.
o Administering naloxone in emergencies
 In most cases, RNs and RPNs need an order to perform the controlled act
of administering a substance by injection or inhalation. However, the
RHPA lists several exceptions when people can perform controlled acts
in defined circumstances. One of these is when you are providing first
aid or temporary assistance in an emergency. Nevertheless, your practice
environment (such as the client population, types of services you provide
and chance of unpredictable events occurring) affect whether or not this
emergency exception applies.
 Nurses are permitted to distribute naloxone when it is indicated for
emergency use for opioid overdose outside hospital settings. Naloxone no
longer requires a prescription under such circumstances.
o Administering cannabis

The Cannabis Regulations provides nurses with the legal authority to:

Distribute or sell to a patient a cannabis product[1], other than
cannabis plants or cannabis seeds, upon receipt of a medical
document or written order.
o Medication samples
 Pharmaceutical representatives often leave medication samples at the
clinic where I work as a nurse. Can I provide a medication sample to
patients?
 Under federal law, nurse practitioners can accept and distribute medication
samples to patients.
 If medication samples are being accepted in your practice setting there
should be clear policies and guidelines on how medication samples are
accepted, stored and used to support safe patient care. This includes
whether your practice setting supports nurses in providing sample
medications to patients.
o Administering OTC medications

Over-the-counter (OTC) medications do not require a prescription and
nurses may recommend or administer them to a patient. However, in some
practice settings, legislation or organizational policy might require an
order.
o Psychiatric nurse

Like many nursing regulators in Canada, CNO takes a generalist
approach to the nursing education needed to practice as a
Registered Nurse (RN) or a Registered Practical Nurse (RPN). This
ensures all Ontario nurses have the knowledge, skill and judgment
to provide safe care to people of all genders and ages, in various
practice settings, communities and populations. Once registered,
Ontario nurses can decide to pursue a speciality, such as mental
health or addiction. This is one of the ways we meet our mandate to
protect the public.

In Alberta, British Columbia, Manitoba and Saskatchewan
psychiatric nursing is regulated as a separate profession. However,
in these provinces, a psychiatric nursing program is recognized
only for practice as a Registered Psychiatric Nurse, not as an RN or
RPN.
______________________________________________________________________
_________________
Confidentiality & Privacy- Personal Health Information
https://www.cno.org/globalassets/docs/prac/41069_privacy.pdf
o Personal Health Information Protection Act

The Personal Health Information Protection Act, 2004 (PHIPA) governs
health care information privacy in Ontario. Information privacy is defined
as the client’s right to control how his/her personal health information is
collected, used and disclosed. PHIPA sets consistent rules for the
management of personal health information and outlines the client’s rights
regarding his/her personal health information. This legislation balances a
client’s right to privacy with the need of individuals and organizations
providing health care to access and share health information.

PHIPA permits the sharing of personal health information among health care team
members to facilitate efficient and effective care. The health care team includes
all those providing care to the client, regardless of whether they are employed by
the same organization. PHIPA requires that personal health information be kept
confidential and secure. Security refers to the processes and tools that ensure
confidentiality of information. When using computers, nurses should refer to the
Documentation, Revised 2008 practice standard.
o Quality of Care Information Protection Act

The Quality of Care Information Protection Act, 2016 (QOCIPA) is another piece
of legislation for the health care sector. This Act provides broad protection to
quality of care information produced by a health care facility or a health care
entity, or for a governing or regulatory body. Its purpose is to promote open
discussion of adverse events, peer review activities and quality of care
information, while protecting this information from being used in litigation or
accessed by clients. This means that nurses’ activities and records associated with
the College’s Quality Assurance Program cannot be used in legal proceedings.
o What is personal health information act?

This includes information collected by nurses during the course of therapeutic
nurse-client relationships. Such information relates to the following:

physical or mental health, including family health history;

care provided (including the identification of people providing care);

a plan of service (under the Fixing Long-Term Care Act, 2021);

payments or eligibility for health care;

donation of body parts or substances (e.g., blood), or information gained
from testing these body parts or substances;

a person’s health number; or

the name of a client’s substitute decision-maker. Clients do not have to be
named for information to be considered personal health information.
Information is “identifying” if a person can be recognized, or when it can
be combined with other information to identify a person. Personal health
information can also be found in a “mixed record,” which includes
personal information other than that noted above.

Nurses in independent practice, or those employed in health services in
non-health care settings may be considered custodians. Nurses in these
settings are responsible for the personal health information in their custody
and control, and must take certain steps to safeguard it. Compliance under
the Act includes the following:

designating a contact person to facilitate compliance with the Act
and to respond to requests, inquiries and complaints from the
public;

providing a written public statement generally describing
information practices, how to reach the contact person, the process
for accessing records or requesting corrections, and the complaint
process for clients; PRACTICE STANDARD 5 College of Nurses
of Ontario Practice Standard: Confidentiality and Privacy—
Personal Health Information

ensuring information practices comply with the Act and its
regulations

ensuring information is accurate, complete and up-to-date and

ensuring information is secure
______________________________________________________________________
_________________
Decisions About Procedures & Authority
https://www.cno.org/globalassets/docs/prac/41071_decisions.pdf
1. Appropriate health care provider: Nurses must consider each situation to determine if the
performance of the procedure promotes safe client care, and if it is appropriate for a nurse to
perform the procedure.
2. Authority: Nurses ensure that they have the appropriate authority before performing
procedures.
3. Competence: Nurses ensure that they are competent in both the cognitive and technical aspects
of a procedure prior to performing it.
4. Managing outcomes: Prior to performing procedures, nurses ensure that they are able to
identify the potential outcomes of procedures, have the authority and competence to manage the
outcomes, or have the resources available to manage those outcomes.
o Controlled acts authorized to RNs and RPNs
RNs and RPNs are authorized to perform the following controlled acts under the Nursing
Act.

Performing a prescribed procedure below the dermis or a mucous
membrane.

Administering a substance by injection or inhalation.

Putting an instrument, hand, or finger
o i. beyond the external ear canal,
o
ii. beyond the point in the nasal passages where they
normally narrow,
o iii. beyond the larynx, iv. beyond the opening of the
urethra, v. beyond the labia majora,
o vi. beyond the anal verge, or vii. into an artificial opening
into the body.

The RHPA includes a number of exceptions that permit persons who are
not members of a regulated profession to perform controlled acts in
defined circumstances. These exceptions are described in Appendix C.
PRACTICE STANDARD 15 College of Nurses of Ontario Practice
Standard: Decisions About Procedures and Authority 4. Dispensing a
drug. 5. Treating, by means of psychotherapy technique, delivered through
a therapeutic relationship, an individual’s serious disorder of thought,
cognition, mood, emotional regulation, perception or memory that may
seriously impair the individual’s judgement, insight, behaviour,
communication or social functioning. An RN or RPN is authorized to
perform a procedure within the other controlled acts authorized to nursing:

if initiated (see Appendix D) in accordance with conditions identified in
the regulation; or

if the procedure is ordered by a physician, dentist, chiropodist, midwife or
NP. Controlled acts authorized to NPs NPs have successfully completed
an approved education program and passed an examination to give them
the authority under the Nursing Act to perform the following controlled
acts.

Communicating to a client or a client’s representative, a diagnosis made
by the NP identifying as the cause of a client’s symptoms, a disease or
disorder.

Performing a procedure below the dermis or a mucous membrane.

Putting an instrument, hand or finger,
o i. beyond the extarenal ear canal
o ii. beyond the point in the nasal passages where they normally
narrow
o iii. beyond the larynx
o iv. beyond the opening of the urethra v. beyond the labia majora
o vi beyond the anal verge, or
o vii. into an artificial opening of the body.

Applying or ordering the application of a prescribed form or energy.

Setting or casting a fracture of a bone or dislocation of a joint.

Administering a substance by injection or inhalation, in accordance with
the regulation, or when it has been ordered by another health care
professional who is authorized to order the procedure.

Prescribing, dispensing, selling, or compounding a drug in accordance
with the regulation.

Treating, by means of psychotherapy technique, delivered through a
therapeutic relationship, an individual’s serious disorder of thought,
cognition, mood, emotional regulation, perception or memory that may
seriously impair the individual’s judgement, insight, behaviour,
communication or social functioning.
o Controlled Acts established in the RHPA
The RHPA established 14 controlled acts. A regulated health care professional is
authorized to perform a portion or all of the specific controlled acts that are appropriate
for the professional’s scope of practice.
1. Communicating to the individual or his/her personal representative a diagnosis
identifying a disease or disorder as the cause of symptoms of the individual in
circumstances in which it is reasonably possible that the individual or his/her personal
representative will rely on the diagnosis.
2. Performing a procedure on tissue below the dermis, below the surface of a mucous
membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth,
including the scaling of teeth.
3. Setting or casting a fracture of a bone or dislocation of a joint.
4. Moving the joints of the spine beyond the individual’s usual physiological range of
motion using a fast, low-amplitude thrust.
5. Administering a substance by injection or inhalation.
6. Putting an instrument, hand or finger:
i. beyond the external ear canal, ii. beyond the point in the nasal passages where
they normally narrow,
iii. beyond the larynx, iv. beyond the opening of the urethra, v. beyond the labia
majora, vi. beyond the anal verge, or vii. into an artificial opening into the body.
7. Applying or ordering the application of a form of energy prescribed by the regulations
under this Act.
8. Prescribing, dispensing, selling or compounding a drug as defined in clause 113(1)(d)
of the Drug and Pharmacies Regulation Act or supervising the part of a pharmacy where
such drugs are kept.
9. Prescribing or dispensing, for vision or eye problems, subnormal vision devices,
contact lenses or eye glasses other than simple magnifiers.
10. Prescribing a hearing aid for a hearing-impaired person.
11. Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance or a
device used inside the mouth to protect teeth from abnormal functioning.
12. Managing labour or conducting the delivery of a baby.
13. Allergy-challenge testing of a kind in which a positive result of the test is a
significant allergic response.
14. Treating, by means of psychotherapy technique, delivered through a therapeutic
relationship, an individual’s serious disorder of thought, cognition, mood, emotional
regulation, perception or memory that may seriously impair the individual’s judgement,
insight, behaviour, communication or social functioning.
ETHICS
https://www.cno.org/globalassets/docs/prac/41034_ethics.pdf
Different types of ethical conflicts
1. Client Wellbeing
a. Nurses demonstrate a regard for client well-being by:
i. listening to, understanding and respecting clients’ values,
opinions, needs and ethnocultural beliefs;
ii. supporting clients to find the best possible solution, given clients’
iii.
iv.
v.
vi.
vii.
viii.
ix.
personal values, beliefs and different decision-making styles;
using their knowledge and skill to promote clients’ best interests
in an empathic manner;
promoting and preserving the self-esteem and selfconfidence of
clients;
maintaining the therapeutic nurse-client relationship;
seeking assistance when ethical conflicts arise (for example, from
colleagues, ethics committees, clergy, literature);
trying to improve the level of health care in the community by
working with individuals, groups, other health care professionals,
employers or government staff to advocate for needed health
policy and health resources;
respecting the informed, voluntary decisions of clients, including
participants in research; and
minimizing risks and maximizing benefits to clients and research
participants (CNA, 1994).
2. Client Choice
a. Nurses demonstrate regard for client choice by:
i. respecting clients even when the clients’ wishes are not the same
as theirs;
ii. following clients’ wishes within the obligations of the law and the
standards of practice;
iii. following substitute decision-makers’ directives if clients are
incompetent to make decisions about their care, within the
obligations of the law and standards of practice;
iv. exploring clients’ rationales for their decisions before acceding to
wishes that the nurse disagrees with. (Can other options be found
that coincide with client wishes and the nurse’s knowledge and
judgment?);
v. supporting informed decision-making;
advocating for clients to acquire information before consenting
to, or refusing, care, treatment or to be a research participant;
and
vi. making a reasonable effort to identify a substitute decision-maker
if a client is not competent to make choices regarding health care.
3. Privacy and Confidentiality
a. Nurses demonstrate regard for privacy and confidentiality by:
i. keeping all personal and health information confidential within
the obligations of the law and standards of practice, including that
which is documented or stored electronically. (For further
information, see the Documentation, Revised 2008 practice
standard);
ii. informing clients or substitute decision-makers that other health
care team members will have access to any information obtained
while caring for clients;
iii. informing clients or substitute decision-makers who comprise the
health care team;
iv. informing clients or substitute decision-makers that information
may be used for purposes other than client care (e.g., research,
quality improvements);
v. refraining from collecting information that is unnecessary for the
provision of health care; and
vi. protecting clients’ physical and emotional privacy
4. Respect for Life
a. Nurses demonstrate regard for respect for life by:
i. identifying, when possible, clients’ values about respect for life
and quality of life;
ii. respecting clients’ values and following their wishes within the
obligations of the law and standards of practice;
iii. following substitute decision-makers’ directives if clients are
incompetent to make decisions about their care, within the
obligations of the law and standards of practice;
iv. advocating for palliative measures when active treatment is
withheld; and
v. providing dignified, comfortable care for a dying client.
5. Maintaining Commitments
a. Nurses demonstrate a regard for maintaining commitments to clients by:
i. putting the needs and wishes of clients first;
ii. identifying when a client’s needs and wishes conflict with those of
the family or others and encouraging further discussion about
client needs;
iii. identifying needed resources and support to enable clients to
follow their wishes;
iv. identifying when their own values and beliefs conflict with the
ability to keep implicit and explicit promises and taking
appropriate action;
v. providing knowledgeable and client-centred nursing care;
vi. advocating for maintaining quality client care; and
vii. making all reasonable efforts to ensure that client safety and wellbeing is maintained during any job action.
6. Maintaining Commitments to Oneself
a. Nurses demonstrate a regard for maintaining commitments to
themselves by:
i. clarifying their own values in client situations;
ii. identifying situations in which a conflict of their own values
interferes with the care of clients;
iii. exploring alternative options for treatment and seeking
consultation when values conflict;
iv. determining and communicating their values pertinent to a
position before accepting it; and
v. recognizing their physical and mental limitations, and the impact
their own health has on their ability to provide safe, effective and
ethical care.
7. Maintaining commitment to colleagues
8. Maintaining commitment to nursing profession
9. Maintaining Commitment to team members and others
10. Maintainign commitment to quality practice setting
11. Truthfullness
12. Fairness
o
Working Through Ethical Situations in Nursing Practice
o Because of the nature of ethics, it is sometimes difficult to identify precisely the
issues causing the ethical situation. Complex, moral and value laden situations
are not easily understood and dealt with. Working through ethical situations
begins with understanding the values of all concerned.
o Because nearly every ethical situation involves other members of the health care
team, these people need to be part of the discussion to resolve the issues and
develop an acceptable plan of care. An ethics resource person in the agency,
such as an ethicist, clergy member or ethics committee, can also be of
assistance. Other resources are literature, CNO Practice Consultants and the
Joint Centre for Bioethics at the University of Toronto. There are many ways of
working through and understanding ethical situations. One example of how to
do this is included in this section. For other examples, refer to the bibliography,
which begins on page 19. Due to its familiarity to nurses, the nursing process
provides a viable approach for examining situations involving ethical values.
These situations may involve ethical uncertainty, ethical distress or ethical
conflicts. Assessment/description of situation
o Pay close attention to all aspects of the situation, taking into account clients’
beliefs, values, wishes and ethnocultural backgrounds.
o Examine not only your beliefs, values and knowledge (see Maintaining
Commitments to Oneself on page 9), but also those of others on the health care
team.
o Consider policies and guidelines, professional codes of ethics and relevant
legislation.
o Hold a discussion with all involved to clarify the process. When thoughtful
consideration has been given to all of these factors, the nature of the concern is
clarified and the issues are identified.
o
o
o
o
o
o
o
o
o
o
o
o
o
Clearly state the ethical concern, issue, problem or dilemma.
Identify a broad range of options and their consequences. Options that at first
may not seem feasible need to be considered as a way of strengthening analysis
and decision-making. For example, staff may believe that client care is
compromised. One option is to look at staffing and hire more staff, but fiscal
restraints make it impossible. Looking at staffing, however, may lead to
reorganizing the workload to allow nurses to concentrate more fully on nursing
care, helping to alleviate the problem. Plan/approach
Develop an action plan that takes into account factors drawn from the
assessment, options and consequences. Sometimes doing nothing is the best
course of action. This should be a conscious decision, since doing nothing will
affect the outcome and should not be a means of avoiding a decision.
Decide which is the best course of action. Sometimes a completely good
outcome is impossible; the best possible outcome may be the one that is least
bad. (In a case of staff shortages, it may be that reorganizing the work allows
nurses to give safe care, although the nurses may still believe that the quality of
care is reduced.)
Consult with anyone who disagrees and consider her/his position. Perhaps a
further assessment of the situation needs to take place, and the dissenting
person needs to be involved in the planning. If a person is involved in the
decision making process but disagrees with the final plan, she/he has an
obligation to respect the decision made. If she/he cannot accept the decision,
she/he needs to arrange for another caregiver and withdraw from the situation.
(For more information, see Maintaining Commitments to Oneself on page 9.)
Implementation/action
Carry out the agreed upon actions. Sensitivity, good communication and
interpersonal skills are necessary. All who are affected by the situation need to
be kept informed.
Provide information and emotional support for the client, the family, friends and
caregivers; implementation may be very stressful. Evaluation/outcome
Determine if the result is satisfactory.
Involve those who were part of the initial assessment and planning, including the
client.
Reassess and re-plan if others are concerned with the outcome. For example, a
client refuses a recommended treatment. The team has done everything
possible to inform the client of the College of Nurses of Ontario Practice
Further assessment might uncover ethnocultural beliefs that make it impossible
for the client to agree to the treatment. In light of this information, the team can
either recommend another treatment or accept the client’s decision.
Consider policies and guidelines for subsequent situations and decisions, and
revise them as necessary.
Assess the time allowed for ethical decision making. Many ethical dilemmas
occur when there is not enough time to consider the issues properly. Evaluation
will help sensitize participants to ethical thinking and improve their ability to
work through
Medication
https://www.cno.org/globalassets/docs/prac/41007_medication.pdf
To administer a medication, nurses must have:
o The authority
o Safety
o Competence
Nurse Client Relationship
https://www.cno.org/globalassets/docs/prac/41033_therapeutic.pdf
5 Aspects of Nurse-Client relationship
1. Trust
2.
3.
4.
5.
o
1.
2.
3.
4.
Trust is critical in the nurse-client relationship because the client is in a vulnerable
position. Initially, trust in a relationship is fragile, so it’s especially important that a nurse
keep promises to a client. If trust is breached, it becomes difficult to re-establish.
Respect. Respect is the recognition of the inherent dignity, worth and uniqueness of
every individual, regardless of socio-economic status, personal attributes and the nature
of the health problem.
Professional intimacy
Professional intimacy is inherent in the type of care and services that nurses provide. It
may relate to the physical activities, such as bathing, that nurses perform for, and with,
the client that create closeness. Professional intimacy can also involve psychological,
spiritual and social elements that are identified in the plan of care. Access to the client’s
personal information, within the meaning of the Freedom of Information and Protection
of Privacy Act, also contributes to professional intimacy.
Empathy.
Empathy is the expression of understanding, validating and resonating with the 1 In this
document, nurse refers to a Registered Practical Nurse (RPN), Registered Nurse (RN) and
Nurse Practitioner (NP). In nursing, empathy includes appropriate emotional distance
from the client to ensure objectivity and an appropriate professional response.
Power.
The nurse-client relationship is one of unequal power. Although the nurse may not
immediately perceive it, the nurse has more power than the client. The nurse has more
authority and influence in the health care system, specialized knowledge, access to
privileged information, and the ability to advocate for the client and the client’s
significant others.7 The appropriate use of power, in a caring manner, enables the nurse
to partner with the client to meet the client’s needs. A misuse of power is considered
abuse.
Four Standard Statements
Therapeutic Communication
Client-centred care
Maintaining Boundaries
Protecting clients from abuse
Authorizing Mechanisms
https://www.cno.org/globalassets/docs/prac/41075_authorizingmech.pdf
The scope of practice statement for nursing is as follows:
The practice of nursing is the promotion of health and the assessment of the provision of care
for and the treatment of health conditions by supportive, preventive, therapeutic, palliative and
rehabilitative means in order to attain or maintain optimal function.
o
Controlled acts are defined as acts that could cause harm if performed by those who do
not have the knowledge, skill and judgment to perform them.
o
ALL nurses are authorized to perform the following controlled acts:
1. Performing a prescribed procedure below the dermis or a mucous membrane.
2. Administering a substance by injection or inhalation.
3. Putting an instrument, hand or finger
i. beyond the external ear canal, ii. beyond the point in the nasal passages where
they normally narrow,
iii. beyond the larynx, iv. beyond the opening of the urethra,
v. beyond the labia majora, vi. beyond the anal verge, or
vii. into an artificial opening into the body.
4. Dispensing a drug.
5. Treating, by means of psychotherapy technique, delivered through a therapeutic
relationship, an individual’s serious disorder of thought, cognition, mood, emotional
regulation, perception or memory that may seriously impair the individual’s judgement,
insight, behaviour, communication or social functioning.
o
Controlled acts authorized to NPs
NPs can perform the following controlled acts:
1. Communicating to a client or client’s representative a diagnosis made by the NP
identifying as the cause of a client’s symptoms, a disease or disorder.
2. Performing a procedure below the dermis or a mucous membrane.
3. Putting an instrument, hand or finger,
i. beyond the external ear canal ii. beyond the point in the nasal passages where
they normally narrow
iii. beyond the larynx iv. beyond the opening of the urethra
v. beyond the labia majora vi. beyond the anal verge, or vii. into an artificial
opening of the body.
4. Applying or ordering the application of a prescribed form of energy.
5. Setting or casting a fracture of a bone or dislocation of a joint.
6. Adminstering a substance by injection or inhalation, in accordance with the
regulation, or when it has been ordered by another health care professional who is
authorized to order the procedure.
7. Prescribing, dispensing, selling and compounding a drug in accordance with the
regulation.
8. Treating, by means of psychotherapy technique, delivered through a therapeutic
relationship, an individual’s serious disorder of thought, cognition, mood, emotional
regulation, perception or memory that may seriously impair the individual’s judgement,
insight, behaviour, communication or social functioning.
o
Direct orders

A direct order is client-specific. A health care professional—such as a
physician, midwife, dentist, chiropodist or NP, or an RN who is initiating a
controlled act—can give a direct order for a specific intervention to be
administered at a specific time or times. A direct order may be written or
verbal (oral). Verbal orders must only be used in emergency situations or
when the prescriber is unable to document the order, such as in the
operating room. There is an inherent risk in accepting a verbal order, and
nurses should advocate for systems that allow their use only in
emergency situations or when the order is unable to be documented.
Procedures that necessitate direct assessment of the client by the
authorizer, such as when the client’s condition becomes unstable, require
direct orders.
o
Directives

A directive is an order for a procedure or series of procedures that may
be implemented for a number of clients when specific conditions are met
and specific circumstances exist. A directive is always written by a
regulated health professional who has the legislative authority to order
the procedure for which she/he has ultimate responsibility. Although a
directive is a medical document, the College recommends that every
health care professional who is affected by the directive be involved in its
development to determine whether a directive is most appropriate for
the client, or if direct assessment of the client by the authorizer is
required before treatment proceeds.
o
Conditions for initiating controlled acts
 Competence
 Client factors
 Environmental supports
 Documentation requirements
 The person who is initiating must document the initiation and
outcome in the client chart
 A nurse’s accountabilities The person who is initiating must accept
accountability for the decision to initiate the procedure and ensure that
any potential outcomes are managed.
o
NPs cannot delegate:
 prescribing, dispensing, selling or compounding medication

ordering the application of a form of energy setting a fracture or
joint dislocation
 treating, by means of psychotherapy technique, delivered through
a therapeutic relationship, an individual’s serious disorder of
thought, cognition, mood, emotional regulation, perception or
memory that may seriously impair the individual’s judgement,
insight, behaviour, communication or social functioning.
o
o
Requirements for delegating
A nurse may delegate when all the following requirements have been met:
 Requirement 1 The nurse has the authority under the Nursing Act to
perform the controlled act.
 Requirement 2 The nurse has the knowledge, skill and judgment to
perform the controlled act safely and ethically.
 Requirement 3 The nurse has a nurse-client relationship with the client
for whom the controlled act will be performed.
 Requirement 4 The nurse has considered whether the delegation of the
controlled act is appropriate, keeping in mind the best interests and
needs of the client.
 Requirement 5 The nurse takes reasonable steps to ensure that she/he is
satisfied that sufficient safeguards and resources are available to the
delegatee so that the controlled act can be performed safely and
ethically.
 Requirement 6 The nurse has considered whether the delegation should
be subject to any conditions15 to ensure that it is performed safely and
ethically, and has made the delegation subject to conditions, if
applicable.
 Requirement 7 After taking reasonable steps, the nurse is satisfied that
the delegatee is a person who is permitted to accept the delegation and
is:
 a nurse who has a nurse-client relationship with the client
 a health care provider who has a professional relationship with
the client
 a person in the client’s household, or
 a person who routinely provides assistance or treatment for the
client.
 Requirement 8 When the delegatee is a nurse or other regulated health
professional, the nurse must be satisfied that the delegatee has the
knowledge, skill and judgment to perform the controlled act safely and
ethically. When the delegatee is not a regulated health professional, the
nurse must be satisfied that the delegatee has the knowledge, skill and
judgment to perform the controlled act safely and ethically and that the
delegation is appropriate for the client.
 Requirement 9 If the nurse has delegated a controlled act but has reasonable
grounds to believe that the delegatee no longer has the ability to perform
the controlled act safely and ethically, the nurse must immediately cease to
delegate the controlled act to that delegatee.
 Requirement 10 The delegating nurse shall: a) ensure that a written record of
the particulars of the delegation is available in the place where the controlled
act is to be performed, before it is performed or b) ensure that a written
record of the particulars of the delegation, or a copy of the record, is placed
in the client record at the time the delegation takes place or within a
reasonable period of time afterwards or c) record particulars of the
delegation in the client record either at the time the delegation takes place
or within a reasonable period of time afterwards. The particulars of
delegation must include those mentioned in “Documenting the particulars of
delegation” below.
o
Requirements for Accepting Delegation
o A nurse may accept delegation when all the following requirements have been
met:
 Requirement 1 The nurse has the knowledge, skill and judgment to
perform the controlled act safely and ethically.
 Requirement 2 The nurse has a nurse-client relationship with the client
for whom the controlled act is to be performed.
 Requirement 3 The nurse has considered whether performing the
controlled act is appropriate, keeping in mind the best interests and
needs of the client.
 Requirement 4 After taking reasonable steps, the nurse is satisfied that
there are sufficient safeguards and resources available to ensure that the
controlled act can be performed safely and ethically.
 Requirement 5 The nurse has no reason to believe that the delegator is
not permitted to delegate that controlled act.
 Requirement 6 If the delegation is subject to any conditions, the nurse
has ensured that the conditions have been met.
 Requirement 7 Nurses who perform a controlled act that was delegated
to them must record the particulars of the delegation in the client record,
unless: a) a written record of the particulars of the delegation is available
in the place where the controlled act is to be performed or (b) a written
record of the particulars of the delegation, or a copy of the record, is in
the client record or (c ) the particulars of the delegation have already
been recorded in the client record.
Conflict Prevention and Management
https://www.cno.org/globalassets/docs/prac/47004_conflict_prev.pdf
Nurse-client conflict
o Conflict between a nurse and a client can escalate if a client is:
a) intoxicated or withdrawing from a substanceinduced state;
b) being constrained (for example, not being permitted to smoke) or restrained
(for example, with a physical or chemical restraint);
c) fatigued or overstimulated; and/or
d) tense, anxious, worried, confused, disoriented or afraid.
o
Conflict between a nurse and a client can escalate if a client has:
a) a history of aggressive or violent behaviour, or is acting aggressively or violently
(for example, using profane language or assuming an intimidating physical stance);
b) a medical or psychiatric condition that causes impaired judgment or an altered
cognitive status;
c) an active drug or alcohol dependency or addiction;
d) difficulty communicating (for example, has aphasia or a language barrier exists);
and/or
e) ineffective coping skills or an inadequate support network
o
Conflict between a nurse and a client can escalate if a nurse:
a) judges, labels or misunderstands a client;
b) uses a threatening tone of voice or body language (for example, speaks loudly
or stands too close);
c) has expectations based on incorrect perceptions of cultural or other differences;
d) does not listen to, understand or respect a client’s values, opinions, needs and
ethnocultural beliefs
e) does not listen to the concerns of the family and significant others, and/or act
on those concerns when it is appropriate and consistent with the client’s wishes;
f) does not provide sufficient health information to satisfy the client or the client’s
family; and/or
g) does not reflect on the impact of her/his behaviour and values on the client.
Nurse-colleague conflict
o Conflict among colleagues can escalate if:
a) bullying or horizontal violence exists;
b) barriers to collaborative collegial behaviour encourage the marginalization of
others18 (for example, formation of identity groups based on culture or religion);
c) different practice perspectives are accentuated by factors such as age, length
of service, generation gap, culture and education level;
d) team members do not support each other in achieving work responsibilities or
meeting learning needs;
e) colleagues are intentionally or unintentionally put into situations beyond their
capabilities;20
f) new graduates and/or employees are not supported by experienced nurses21
and/or systemic orientation practices;
g) fear of reprisal impedes the reporting of conflict by staff; and/or
h) there is a lack of awareness about the need to anticipate and manage conflict.
o Prevention

As members of the health care team, nurses must be able to work
in cooperation with colleagues to deliver safe, effective and ethical
client care.
 Unresolved conflict among colleagues may hinder communication,
collaboration and teamwork, which negatively affects client care.
In addition, nurses are less likely to be abused by clients if they do
not tolerate abuse among colleagues.
 Nurses can employ consistent strategies to help prevent conflict
among colleagues from escalating.
 Nurses can:
 a) promote a respectful work environment by modelling
professional behaviours
 b) mentor, support and integrate new staff members into
the practice setting;
 c) reflect on personal attitudes, motivators, values and
beliefs that affect relationships with colleagues, identify
personal areas in need of improvement and strive to alter
their own behaviour in situations that have previously
ended in conflict; and
d) recognize that personal stress may affect professional
relationships and take steps to manage that stress
______________________________________________________________________________
Consent
https://www.cno.org/globalassets/docs/policy/41020_consent.pdf
The Health Care Consent Act (HCCA)
o The goals of the HCCA include promoting individual authority and autonomy,
facilitating communication between health care practitioners and their clients,
and ensuring a significant role for family members when the client is incapable of
consenting.
o The HCCA deals separately with consent to treatment, consent to a care facility
and consent to a personal assistance service. In all cases, consent must be given
by a capable person.
o Consent to treatment, and assessing the capacity to consent to treatment, must
relate to a specific treatment or plan of treatment. A person could be capable of
giving consent to one treatment, but incapable with respect to another.
o Consent to treatment involves an ongoing process that can change at any time.
o Health care practitioners have no authority to make treatment decisions on
behalf of clients, except in an emergency when no authorized person is available
to make the decisions. Similarly, they have no authority to make a decision to
consent to the admission of a client to a care facility, except in a crisis.
o Assessing the client’s capacity to make a treatment decision is the responsibility
of the health care practitioner proposing the treatment.
o An evaluator determines client capacity to make a decision about admission to a
care facility or a personal assistance service. Registered Nurses (RNs), Registered
Practical Nurses (RPNs) and Nurse Practitioners (NPs) may be evaluators.
o The client has the right to ask the Consent and Capacity Board (CCB) to review the
finding of incapacity.
o Minor adjustments to a treatment plan for an incapable client can be made
without having to seek repeated consent from a substitute decisionmaker.
o One health care practitioner can propose a plan of treatment and obtain consent
to the plan on behalf of all the health care practitioners involved in the plan.
o When a health care practitioner finds a client is incapable of making a treatment
decision, the legislation requires the practitioner to provide the client with
information about the consequences of the finding. This provision of information
must be performed in accordance with guidelines established by the practitioner’s
governing body. The guidelines for nurses are in Appendix A.
o A family member acting as a substitute decisionmaker is not required to make a
formal statement verifying his/her status. The legislation does contain a hierarchy
of substitute decision-makers.
o A person’s wishes about treatment, admissions or personal assistance services
may be expressed orally, in writing, in any other form, or they may be implied.
The Substitute Decisions Act (SDA)
o The SDA deals with decision-making about personal care or property on behalf of
incapable persons. Whereas the HCCA is concerned with the capacity to make decisions
in relation to specific treatment, admission to care facilities or personal assistance
services, the SDA is concerned with persons who need decisions made on their behalf on
a continuing basis.
o It involves the formal appointment of a decision-maker through a power of attorney
document, through the Office of the Public Guardian and Trustee (PGT) or through a court
appointment.
o Here are some of the major features of the SDA:
 An individual may designate a specific person to make decisions about
his/her personal care or treatment in the event that he/she becomes
incapable. The person may also express his/her wishes about the kinds of
decisions to be made or factors to guide decisions.




o
o
o
o
o
o
The Office of the PGT is the government department that deals with
personal care and property matters.
Only trained capacity assessors may determine capacity for the purpose of
the SDA (i.e., the capacity to make decisions on an ongoing basis). The
HCCA requires assessment of capacity to make decisions about a specific
treatment.
A power of attorney for personal care comes into effect when the person
who granted it becomes mentally incapable, unless it states otherwise.
A person under statutory guardianship may apply to the CCB for a review
of a finding of incapacity.

Substitute decision-maker:
 A person identified by the HCCA who may make a treatment decision for
someone who is incapable of making his/her own decision. The HCCA
provides a hierarchy to determine who is eligible to be a substitute
decisionmaker. The substitute decision-maker is usually a spouse, partner
or relative. A power of attorney for personal care is not necessarily
required to act as a substitute decision-maker.
Consent and Capacity Board (CCB):
 A board established by and accountable to the government. Its members
are appointed by the government. The Board considers applications for
review of findings of incapacity, applications relating to the appointment
of a representative, and applications for direction regarding the best
interests and wishes of an incapable person.
Spouse:
 Two persons who are married to each other, or who are living in a conjugal
relationship and have cohabited for at least a year, or who are the parents
of a child or who have a cohabitation agreement under the Family Law Act.
Partners:
 Two persons who have lived together for at least one year and have a close
personal relationship that is of primary importance in both persons’ lives.
Relatives:
 Two persons related by blood, marriage or adoption.
Public Guardian and Trustee (PGT):
 The PGT is the substitute decision-maker of last resort for a mentally
incapable person. The court will not appoint the PGT as guardian of
property or guardian of the person unless there is no other suitable person
available and willing to be appointed.
Steps to Obtaining Consent
STEP 1: Assess capacity
1. Capacity
a. understands the information that is relevant to making a decision concerning the
treatment, admission or personal assistance service; and
b. appreciates the reasonably possible consequences of a decision or lack of a
decision.
2. Age of consent
a. There is no minimum age for giving consent. Health care practitioners and
evaluators should use professional judgment, taking into account the
circumstances and the client’s condition, to determine whether the young client
has the capacity to understand
3. Role of Evaluator
a. An evaluator must determine capacity in the case of admission to a care facility or
provision of personal assistance services. The evaluator may be the person
proposing the admission or services, or the evaluator may be identified by facility
or agency policies. Nurses and some other health care professionals may be
evaluators.
4. Role of capacity assessor
a. A capacity assessor conducts assessments of capacity on persons who need
decisions made on their behalf on a continuing basis. NPs and RNs are eligible to
become capacity assessors. Designation will require the successful completion of
a capacity assessor education or training course approved or required by the
attorney general.
5. Incapable Person
a. If a person is incapable, the consent (or refusal to give consent) is to be obtained
from the highest ranked available substitute decision-maker from the HCCA
hierarchy who is willing to make the decision. If there is no other substitute
decisionmaker, the PGT is the substitute decision-maker of last resort.
Step 2: Provide emergency treatment
Treatment in an emergency can be provided immediately:
o if the person is capable of giving consent and provides the consent;
o in situations where:
o communication can’t take place because of a language barrier or disability, and
o reasonable efforts to overcome the barrier or disability have been made, but a delay will
prolong the suffering the person is apparently experiencing or will put the person at risk
of sustaining serious bodily harm, and there is no reason to believe the person does not
want the treatment;
o incapable with respect to the treatment decision but a substitute decision-maker is
available to give consent; or
o incapable with respect to a treatment, a substitute decision-maker is not readily available,
it is not reasonably possible to obtain a consent or refusal from the substitute, and a delay
will put the person at risk of sustaining serious bodily harm.
o Admission to a care facility without consent may be authorized if:
o the person who has been deemed incapable requires immediate admission
because of a crisis; and
o it is not reasonably possible to obtain immediate consent or refusal on the
incapable person’s behalf.
o
Step 3: Inform client that substitute decision maker will make a decision
Step 4: Identify a substitute decision-maker
Step 5: obtain their consent
The substitute decision-maker giving or refusing consent is expected to make decisions based
on the client’s known wishes, which the client expressed when he/she was 16 years of age or
older and capable. If such wishes are not known, or are impossible to comply with, then the
substitute decision-maker decides in the client’s best interests, taking into account:
o the client’s values and beliefs;
o the impact of the treatment on the client’s condition or well-being;
o whether the benefit outweighs the risk of harm; and
o whether a different treatment would be as beneficial.
o
Directives
https://www.cno.org/globalassets/docs/prac/41019_medicaldirectives.pdf
An order is a prescription for a procedure, treatment, drug or intervention. It can apply to an
individual client by means of a direct order or to more than one individual by means of a
directive. For the purpose of this document, a directive refers to an order from a physician or
Nurse Practitioner (NP).
o A direct order is client specific. It is an order for a procedure, treatment, drug or
intervention for an individual client. It is written by an individual practitioner (for
example, physician, midwife, dentist, chiropodist, NP, or Registered Nurse [RN] initiating
a controlled act) for a specific intervention to be administered at a specific time(s). A
direct order may be written or oral (for example, by telephone). A directive may be
implemented for a number of clients when specific conditions are met and when
specific circumstances exist.
o A directive is always written. For the purpose of this document, a directive refers to an
order from an NP or physician.
When is an order required?
An order is required in any of the following instances:
o when a procedure falls within one of the controlled acts authorized to nursing, in the
absence of initiation.1 For example:
o administering a substance by injection or inhalation,
o performing a procedure below the dermis, or
o putting an instrument, hand or finger beyond a body orifice or beyond an artificial
opening into the body,
o dispensing a drug;
o when a procedure does not fall within any controlled act, but is part of a medical plan
of care;
o when a procedure falls within one of the controlled acts not authorized to nursing;
o when a procedure/treatment/intervention is not included within the Regulated Health
Professions Act, 1991, but is included in another piece of legislation. For example:
o X-rays under the Healing Arts Radiation Protection Act, or
o ordering laboratory tests.
What is in an order?
o the name and description of the procedure(s)/ treatment(s)/intervention(s) being
ordered;
o specific client clinical conditions and situational circumstances that must be met before
the procedure(s) can be implemented;
o clear identification of the contraindications for implementing the directive;
o
the name and signature of the NP or physician approving, and taking responsibility for,
the directive; and
o the date and signature of the administrative authority approving the directive
Policies needed before a directive is used
o identification of the types of procedure(s) that may be ordered by means of a directive.
It must be clear which types of procedure(s) require a direct order, and which may be
implemented when a health care professional has verified that client conditions and
circumstances are met;
o determination of the involvement of the NP/ physician responsible for the care of the
client, such as when a directive may be implemented prior to the NP/physician seeing
the client;
o identification of who may implement a directive, including any specific educational
requirements, designations or competencies (for example, only RNs in a certain
department who have completed a continuing education course, only RNs who have
completed an in-service program, all RNs, or all RNs and Registered Practical Nurses
[RPNs], etc.);
o identification of the NPs or physicians to whom a directive applies. It needs to be clearly
identified whether a directive is meant to apply to the clients of all NPs or physicians or
only clients of selected NPs or physicians;
o development of a feedback mechanism, including a defined communications path. This
enables the health care professional implementing a directive to identify the NP or
physician responsible for the care of the client, and to query the order(s) contained
within the directive if clarification is required;
o clearly stated documentation requirements on the part of the health care professional
implementing a directive; and
o identification of tracking/monitoring methods to identify when directives are being
implemented inappropriately or are resulting in unanticipated outcomes.
It is strongly recommended that the above policies are in place and understood before
directives are used to deliver health care within a facility
Independent Practice
https://www.cno.org/globalassets/docs/prac/41011_fsindepprac.pdf
If you are a self-employed nurse in independent practice, you have options for
incorporating your own business. These include incorporating with the Ontario or federal
government. As a nurse, you also have the option of setting up a Health Professional
Corporation with the College. It is not a requirement, but if you intend to set up a Health
Professional Corporation you will need to be incorporated with the Ontario government.
Regardless of which option you choose, you should discuss your situation with an
accountant or lawyer to determine the best choice for you.
o You are accountable for:
 informing clients in advance of your fees and acceptable methods of
payment
 informing clients in advance of fees for missed appointments or late
payments
 providing clients with adequate notice before changing your fees and
informing clients in advance of what the notice period is
 providing clients with an official receipt listing the nursing services
provided and products sold. Under provincial law,3 the following
activities are considered to be professional misconduct:
 submitting an account or charge for services, which is false or
misleading
 failing to fulfil the terms of an agreement for professional services
 charging a fee that is excessive in relation to the services provided
 charging a fee to be available to provide services to a client
 offering or giving a reduction for prompt payment
 failing to itemize an account for professional services
 selling or transferring any debt owed to you for professional services.
o Nurses in independent practice are expected to obtain professional liability
protection in accordance with current regulatory requirements.
Refusing Assignment/ Discontinuing Nursing Services
https://www.cno.org/globalassets/docs/prac/41070_refusing.pdf
The College has published two documents, Professional Standards, Revised 2002 and Ethics,
that outline the accountabilities and responsibilities of nurses relevant to refusing assignments
and discontinuing nursing services.
Professional Standards, 2002
o A nurse demonstrates accountability by:
 providing, facilitating, advocating and promoting the best possible care
for clients;
 seeking assistance appropriately and in a timely manner;
 taking action in situations in which client safety and well-being are
compromised; and
 maintaining competence and refraining from performing activities for
which she/he is not competent.
 In addition, a nurse in an administrator role demonstrates accountability
by:
 ensuring that mechanisms allow for staffing decisions that are in
the best interest of clients and professional practice; and

advocating for a quality practice environment that supports
nurses’ ability to provide safe, effective and ethical care.
o Professional Misconduct
 The relevant definitions of professional misconduct in the legislation are
found in the following clauses.
 Contravening a standard of practice of the profession or failing to
meet the standard of practice of the profession
 Failing to inform the member’s employer of the member’s
inability to accept specific responsibility in areas where specific
training is required or where the member is not competent
 Discontinuing professional services that are needed unless:
o i. the client requests the discontinuation,
o ii. alternative or replacement services are arranged, or
o iii. the client is given reasonable opportunity to arrange
alternative or replacement services
 Failing to fulfil the terms of an agreement for professional services
 Engaging in conduct or performing an act relevant to the practice of
nursing that having regard to all the circumstances would reasonably
be regarded by members as disgraceful, dishonourable or
unprofessional
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Telepractice
https://www.cno.org/globalassets/docs/prac/41041_telephone.pdf
CNO defines nursing telepractice as the delivery, management and coordination of care and
services provided via information and telecommunication technologies


Nurses’ documentation of provider-to-provider interactions is expected to include:
 date and time of the interaction;
 name of the providers involved;
 name of the patient being discussed (when applicable); ■ reason for the
interaction;
 information provided/received;
 patient information provided/received;
 advice or information given/received;
 any follow-up required/provided;
 any agreement/consensus about the plan of care; and
 the documenting nurse’s signature and designation.
Informed consent is required prior to any assessment and treatment delivered by
telepractice and includes telling the patient:




the nurse’s name, title, class of registration and jurisdiction of registration if
practicing in another jurisdiction;
the nature of the help the nurse will give (e.g., “I will ask you questions and then
provide some information or advice.”);
how to obtain more information or get further questions answered; and
whether the call is being recorded for quality monitoring purposes, either by
telling the caller directly, providing printed notice or having a recorded message
that the caller hears before speaking with a nurse.
o Nurses are expected to keep all personal health information confidential as required
by standards of practice and legislation, including that which is documented or
stored electronically. Refer to the Personal Health Information Protection Act, 2004
(PHIPA) or CNO’s Confidentiality and Privacy — Personal Health Information practice
standard for more details. Nurses demonstrate regard for privacy and confidentiality
of a patient’s personal health information by:
o informing the patient that other health care team members directly involved
in their care will have access to personal health information;
o informing the patient when other health care team members are viewing or
listening to a telepractice interaction;
o obtaining the patient’s consent prior to reporting his/her name as a victim of
abuse; and
o informing the patient of the purpose for permanently retaining a record of a
telepractice interaction (e.g., for teaching). Written consent for
videoconference encounters is recommended by the telepractice industry
* If a complaint is lodged in a jurisdiction outside of Ontario, then the nurses in Ontario who
have provided care to a patient across provincial or national boundaries may be required to
travel to other locations to defend themselves against *
RN and RPN Practice: The Client, the Nurse and the Environment
https://www.cno.org/globalassets/docs/prac/41062.pdf
o The nurse is accountable for:
 her or his actions and decisions
 knowing and understanding the roles and responsibilities of other team
members, and collaborating, consulting and taking action on client
information when needed
 taking action to ensure client safety, including informing the employer of
concerns related to the conduct and/or actions of other care providers,
and College of Nurses of Ontario Practice Guideline: RN and RPN practice:
The Client, the Nurse and the Environment
 collaborating with clients, with each other and with members of the
interprofessional care team for the benefit of the client.
o Decisions about the utilization of an RN and an RPN are influenced by:
o 1. Complexity:
 the degree to which a client’s condition and care requirements are
identifiable and established
 the sum of the variables influencing a client’s current health status, and
 the variability of a client’s condition or care requirements.
o 2. Predictability:
 the extent to which a client’s outcomes and future care requirements can
be anticipated.
o 3. Risk of negative outcomes:
 the likelihood that a client will experience a negative outcome as a result
of the client’s health condition or as a response to treatment.
These 3 factors create a client continuum
The more complex the client situation and the more dynamic the environment, the greater the
need for the RN to provide the full range of care, assess changes, re-establish priorities and
determine the need for additional resources
Working in Different Roles
https://www.cno.org/globalassets/docs/prac/45027_fsdiffroles.pdf
Dual registration refers to nurses who hold registration in more than one category. For
example, a nurse may be registered as a Registered Practical Nurse (RPN) and as a Registered
Nurse (RN). It is important for a nurse holding dual registration to understand her/ his
accountability when working in different roles
o When an RN accepts a position as an RPN, or when an RN or RPN accepts a position as a
UCP, the nurse is expected to fulfil only the requirements of the position’s job
description.
o For example, if the job description does not include administration of medications, CNO
does not expect the nurse to administer medications even though she/he may be
competent to do so.
The following describes the accountability of an RN or RPN working in a UCP role.
o Stable conditions:
 When the client’s health status appears predictable, a nurse working as a
UCP is accountable for:
 knowing and performing within the limits of the UCP role; and
 recognizing when the client’s condition deviates from the norm.
Initial signs of a problem: In the event that symptoms present that
are beyond the expectations of a UCP role, a nurse working as a
UCP is accountable for:
 stepping out of the UCP role to identify and assess the problem as
a nurse;
 ensuring the client receives appropriate care — whether by
communicating the information to a 1 In this document, nurse
refers to Registered Nurse (RN), Registered Practical Nurse (RPN)
and Nurse Practitioner (NP). nurse or by practising as an RN or
RPN if another nurse is unavailable within an appropriate period
of time;
 practising as an RN or RPN until a member practising at the RN or
RPN level is available; and
 assessing why she/he has stepped out of the UCP role.
o Emergency situations: In the event of an emergency situation, the nurse working as a
UCP will immediately function at the RN, NP or RPN level. The member is accountable
for:
 stepping out of the UCP role to identify, assess and respond to the
emergency at the level of her/his RN, NP or RPN preparation;
 practising at the RN, NP or RPN level until a member practising at
the RN, NP or RPN level is available; and
 assessing why she/he has stepped out of the UCP role. For more
information
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