DOS Professionhood Study Notes

Week 1: Entry-to-practice competencies: for registered nurses
● The College of Nurses of Ontario (CNO) is the regulatory body for nursing in Ontario. CNO is
accountable for public protection by ensuring nurses in Ontario practice safely, competently and
ethically. CNO fulfills its mandate through a variety of regulatory activities including
registration, maintaining standards of nursing practice and education, enforcing nursing
standards, conducting continuing competence reviews and establishing competencies required
for nursing practice.
● Entry-to-practice competencies are the foundation for nursing practice. This document outlines
the competencies measured for entry-level registered nurses (RNs) upon initial registration with
CNO and entry to practice in Ontario. The competencies also guide the assessment of members’
continuing competence for maintaining registration with CNO.
● Purpose of the document. The competencies for entry-level RN practice are established for the
following purposes:
Protection of the public: Through government legislation (Nursing Act, 1991 and Regulated
Health Professions Act, 1991), CNO is mandated by the public to promote and ensure safe,
competent and ethical nursing in Ontario.
Practice reference: The competencies are used as a reference or resource to assist RNs to
understand entry-level practice expectations and ongoing applications within their professional
role.
Approval of nursing education programs: The competencies are used by CNO in evaluating
baccalaureate nursing education programs to ensure the curriculum prepares graduates to
successfully achieve professional practice standards before entry to practice.
Registration and membership requirements: The competencies are used by CNO to inform
registration eligibility decisions.
Legal Reference: The legal definition of nursing practice included in the Nursing Act, 1991
establishes the basis for the scope of practice in which any nurse may engage. The competencies
are the expectations for RNs upon entry to practice in Ontario, and are used as a reference when
evaluating the standard of care of registered nurses.
Public information: The competencies inform the public, employers, and other health care
providers about registered nursing practice, and assist with accurate expectations for registered
nursing practice at the entry level.
Continuing competence: In accordance with CNO’s Quality Assurance Program, the
competencies are used by members in the annual self-assessment of their nursing practice and
development of professional learning goals.
Document background:
●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.
Since then, competencies have been revised every five years at a national level to ensure practice
relevance and consistency between jurisdictions.
● 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 territorial nursing regulatory bodies
across the nation.
● This new set of revisions are based on results of an environmental scan, literature reviews and
stakeholder consultation. The regulatory body in each jurisdiction validates and approves the
entryto-practice competencies. They also confirm that the competencies are consistent with
provincial and territorial legislation.
Overarching principles:
The following overarching principles apply to the education and practice of entry-level RNs:
1. Entry-level RNs are beginning practitioners. It is unrealistic to expect an entry-level RN to
function at the level of practice of an experienced RN
2. Entry-level RNs work within the registered nursing scope of practice, and appropriately seek
guidance when they encounter situations outside of their ability
3. Entry-level RNs must have the requisite skills and abilities to attain the entry-level
competencies
4. 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
5. 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
6. Entry-level RNs practice autonomously within legislation, practice standards, ethics and scope
of practice in their jurisdiction
7. Entry-level RNs apply the critical thinking process throughout all aspects of practice.
Definition of client:
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.
Competency framework:
There is a total of 101 competencies organized thematically under nine roles:
1. Clinician
2. Professional
3. Communicator
4. Collaborator
5. Coordinator
6. Leader
7. Advocate
8. Educator
9. Scholar
● The model represents the multiple roles nurses assume when providing, safe, competent,
ethical, compassionate and evidence-informed nursing care in any practice setting. Some
concepts are relevant to multiple roles. For the sake of clarity, and to avoid unnecessary
repetition, certain key concepts (for example, client-centred) are mentioned once and applied to
all competencies.
1. 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 non-pharmacological 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.
2. Professional:
●Registered nurses are professionals who are committed to the health and well-being 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.
3. 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, concisely, accurately, and in a timely manner.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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).
9. 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 (Cultural humility is a
process of self-reflection to understand personal and systemic biases and to develop and maintain
respectful processes and relationships based on mutual trust. Cultural humility involves humbly
acknowledging oneself as a learner regarding understanding another’s experience) 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.
Glossary:
Accountability: The obligation to answer for the professional, ethical and legal responsibilities
of one’s activities and duties (Ellis & Hartley, 2009)
Assessment: Systematically gathering, sorting, organizing and documenting data in a retrievable
format. (Perry, Potter & Ostendorf, 2018)
Assign: Assigning is determining or allocating responsibility for particular aspects of care that
may include controlled and non-controlled act procedures. Assigning care may require nurses to
supervise aspects of care or teach procedures. (College of Nurses of Ontario, 2007)
Client: A client is a person with whom the nurse is engaged in a therapeutic relationship. In most
circumstances, the client is an individual but the client may also include family members and/ or
substitute decision-makers. The client can also be a group (e.g., therapy), community (e.g.,
public health) or population (e.g., children with diabetes). (College of Nurses of Ontario, 2002)
Client Centre An approach in which clients are viewed as whole persons; it is not merely about
delivering services where the client is located. Client centred care involves advocacy,
empowerment, and respecting the client’s autonomy, voice, self-determination, and participation
in decision-making. (Registered Nurses Association of Ontario, 2006)
Compassionate: Showing sensitivity in understanding another person’s suffering, combined with
a willingness to help and promote that person’s well-being. (PerezBret, Altisent & Rocafort,
2016).
Competency: An observable ability of a registered nurse at entry level that integrates the
knowledge, skills, abilities, and judgment required to practise nursing safely and ethically
(Canadian Council of Registered Nurse Regulators, 2013, CanMEDS, 2015)
Competent: The demonstration of integrated knowledge, skills, abilities and judgment required
to practise nursing safely and ethically (College of Nurses of Ontario, 2018a)
Conflict resolution: The various ways individuals or institutions address conflict (for example,
interpersonal, work) to move toward positive change and growth (College of Registered Nurses
of Nova Scotia, 2012)
Continuous quality improvement: A continuous cycle of planning, implementing and evaluating
the effectiveness of strategies, and reflecting to see what further improvements can be made
(College and Association of Registered Nurses of Alberta, 2014)
Critical inquiry: A process of purposive thinking and reflective reasoning through which
practitioners examine ideas, assumptions, principles, conclusions, beliefs, and actions within a
particular context. (Brunt, 2005)
Cultural humility: Cultural humility is a process of self-reflection to understand personal and
systemic biases and to develop and maintain respectful processes and relationships based on
mutual trust. Cultural humility involves humbly acknowledging oneself as a learner regarding
understanding another’s experience. (First Nations Health Authority, 2018)
Cultural safety: An outcome based on respectful engagement that recognizes and strives to
address the health care system’s inherent power imbalances. It results in an environment free of
racism and discrimination, where people feel safe when receiving health care (First Nations
Health Authority, 2018)
Determinants of health: Factors that influence health beyond our individual genetics and lifestyle
choices (Government of Canada, 2018)
Environmentally responsible practice: Practice that supports environmental preservation and
restoration while advocating for initiatives that reduce environmentally harmful practices to
promote health and well-being.
Evidence-informed: How nursing decisions are made with clients, using an ongoing process that
incorporates research, clinical expertise, client preferences and other available resources.
Fitness to practice: Freedom from any cognitive, physical, psychological or emotional condition
or dependence on alcohol or drugs that impairs ability to provide nursing care.
Global Health: The optimal well-being of all humans from the individual and the collective
perspectives. Health is considered a fundamental right and should be equally accessible to all.
Harm Reduction: Policies, programs and practices to reduce adverse health, social and economic
consequences of legal and illegal psychoactive drugs without necessarily reducing drug
consumption
Harmful Incidence: A patient safety incident resulting in harm to patient.
Health care team: A number of health care providers from different disciplines (often including
both regulated professionals and unregulated workers) working together to provide care for and
with persons, families, groups, communities or populations. (Canadian Nurses Association,
2017a)
Health disparities: Differences in health status that occur among population groups defined by
specific characteristics (Health Disparities Task Group of the Federal/Provincial/Territorial
Advisory Committee on Population Health and Health Security, 2004)
Health Inequities: Differences in health status or distribution of health resources between
different population groups, arising from social conditions in which people are born, grow, live,
work and age.
Health literacy: The ability to access, comprehend, evaluate and communicate information as a
way to promote, maintain and improve health in a variety of settings across the life-course.
Health promotion: Enabling people to improve and increase control over their health by moving
beyond individual behaviour toward a wide range of social and environmental interventions.
Holistic: A system of comprehensive or total patient care that considers the physical, emotional,
social, economic, and spiritual needs of the person, the response to illness, and the effect of the
illness to meet self-care needs (Jasemi, Valizadeh, Azmanzadeh & Keogh, 2017)
Information and communication technologies (ICTs): A diverse set of technological tools and
resources used to communicate, create, disseminate, store, and manage information.
Interprofessional: Members from different healthcare disciplines working together towards
common goals to meet the client’s health care needs (Canadian Health Services Research
Foundation, 2012)
Medical Assistance in Dying (MAiD): The situation in which a person seeks and obtains medical
help to end their life. This can be achieved through eitherphysician-assisted suicide or voluntary
euthanasia.
Near miss: A client’s safety incident that did not reach the client and therefore resulted in no
harm.
No harm incidence: A patient safety incident that reached the patient but no discernible harm
resulted.
Nursing informatics: Nursing informatics science and practice integrates nursing, information
and knowledge, and their management, with information and communication technologies to
promote health in people, families, and communities worldwide.
Organizational culture: Member held assumptions and values about their organization that is
different from one organization to the next (Sullivan, 2012)
Palliative care: An approach that improves the quality of life of patients and their families facing
problems associated with life-threatening illness, through preventing and relieving of suffering
by means of early identification, impeccable assessment, and treatment of pain and other
problems (for example, physical, psychosocial and spiritual) (World Health Organization,
2018b)
Plan of care: A plan that includes priority nursing interventions to achieve client centered goals
(College of Registered Nurses of Nova Scotia, 2017a)
Population health: An approach to health that aims to improve the entire population’s health and
to reduce health inequities among population groups. To reach these objectives, it looks at and
acts upon the broad range of factors and conditions that strongly influence our health.
Positional power: The assumed authority or influence a person holds over others by virtue of the
title of his or her position (College of Registered Nurses of Nova Scotia, 2017b)
Primary health care: A focus on delivering client-centred services that include accessibility,
active public participation, health promotion and chronic disease prevention and management,
use of appropriate technology and innovation, and intersectoral cooperation and collaboration
(Canadian Nurses Association, 2015)
Professional Boundaries: The point at which the relationship changes from professional and
therapeutic to unprofessional and personal. It defines the limits of the professional role. Crossing
a boundary means that the care provider is misusing the power in the relationship to meet
personal needs, rather than the needs of the client, or behaving in an unprofessional manner with
the client. The misuse of power does not have to be intentional to be considered a boundary
crossing (CNO, 2006, RNAO, 2006)
Professional presence: The demonstration of confidence, integrity, optimism, passion and
empathy that aligns with legislation, practice standards, and ethics through verbal and nonverbal
communications (Canadian Patient Safety Institute, 2017)
Recovery-oriented nursing care: A perspective that recognizes recovery as a personal process for
people with mental health conditions or addictions to gain control, meaning and purpose in their
lives (Canadian Association of Schools of Nursing, 2015)
Relational practice: Conscious participation with clients using listening, questioning, empathy,
mutuality, reciprocity, self observation, reflection and a sensitivity to emotional contexts (Doane,
& Varcoe, 2007)
Research Skills: The ability to critically appraise the various aspects of a scientific research
study.
Safety: The pursuit of the reduction and mitigation of unsafe acts within the healthcare system,
as well as the use of best practices shown to lead to optimal patient outcomes (Canadian Patient
Safety Institute, 2017)
Scope of practice: roles, functions, and accountabilities that registered nurses are legislated,
educated, and authorized to perform, as defined in Section 3 of the Nursing Act, 1991: “The
practice of nursing is the promotion of health and 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.”
Social justice: Studying and understanding the root causes and consequences of disparities
regarding the unfair distribution of society’s benefits and responsibilities by focusing on the
relative position of one social grouping in relation to others (Canadian Nurses Association,
2017a)
Social media: Software applications (web-based and mobile) allowing creation, engagement and
sharing of new or existing content, through messaging or video chat, texting, blogging and other
social media platforms (Bodell, & Hook, 2014)
Therapeutic nursing intervention: Any treatment, based on clinical judgement and knowledge, a
nurse performs to enhance client outcomes (Butcher, Bulechek, McCloskey Dochterman, &
Wagner, 2019) Therapeutic relationship A relationship a nurse establishes and maintains with a
client, through the use of professional knowledge, skills and attitudes, to provide nursing care
expected to contribute to the client’s wellbeing (Canadian Nurses Association, 2017a)
Trauma-informed care: A strengths-based framework grounded in the understanding of and
responsiveness to the impact of trauma. The framework emphasizes physical, psychological, and
emotional safety for both providers and survivors, and creates opportunities for survivors to
rebuild a sense of control and empowerment (Hopper, Bassuk, & Olivet, 2010)
Legislation and Regulation RHPA: Scope of Practice, Controlled Acts Model
● The scope of practice model is set out in the Regulated Health Professions Act, 1991 (RHPA)
and consists of two elements: a scope of practice statement and a series of authorized or
controlled acts
Scope of Practice Statement:
Each regulated health profession has a scope of practice statement that describes in a general
way what the profession does and the methods that it uses. The scope of practice statement is not
protected in the sense that it does not prevent others from performing the same activities. Rather,
it acknowledges the overlapping scope of practice of the health professions.
Nursing’s Scope of Practice Statement: 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
Controlled Acts:
Controlled acts are activities that are considered to be potentially harmful if performed by
unqualified persons. The 14 controlled acts established in the RHPA are:
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 forseeable 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 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 eyeglasses 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, behavior, communication
or social functioning.
Authorization to Perform Controlled Acts:
●A regulated health professional is authorized to perform a portion or all of the specific
controlled acts that are appropriate for that profession’s scope of practice. Because of overlaps in
practice, some professions are authorized to perform the same, or parts of the same, controlled
acts. On the other hand, not all of the regulated health professions are authorized to perform
controlled acts.
●Note: The RHPA includes a number of exceptions that permit persons to perform controlled act
procedures in defined circumstances. These exceptions are described on the column to the right.
Controlled acts authorized to RNs and RPNs:
RNs and RPNs are authorized to perform the following controlled acts:
1. Performing a prescribed procedure below the dermis or a mucous membrane.
3. Putting an instrument, hand or finger
iii. beyond the larynx,
4. Dispensing a drug.
●A Registered Nurse (RN) or Registered Practical Nurse (RPN) may perform a procedure within
the controlled acts authorized to nursing:
■ if it is ordered by a physician, dentist, chiropodist, midwife or Nurse Practitioner (NP);
or
■ if it is initiated by an RN or RPN in accordance with conditions identified in regulation.
Exceptions to the need for authorization
Acupuncture is exempt from the controlled act of performing a procedure on tissue below the
dermis when it is performed by a nurse in accordance with College standards. Therefore,
authorization (e.g., an order) is not required for nurses to perform acupuncture.
The RHPA also provides several exceptions that allow persons to perform controlled acts. These
exceptions are as follows:
■ when providing first aid or temporary assistance in an emergency;
■ when, under the supervision or direction of a member of the profession, a student is learning
to become a member of that profession and the performance of the procedure is within the scope
of the profession’s practice;
■ when treating a member of a person’s household and the procedure is within the second or
third controlled act authorized to nursing;
■ when assisting a person with his/her routine activities of living and the procedure is within the
second or third controlled act authorized to nursing; or
■ when treating a person by prayer or spiritual means in accordance with the religion of the
person giving the treatment.
NOTE: In addition, a person who performs the following activities is not considered to be in
contravention of the RHPA: ear-piercing or body-piercing for the purpose of accommodating a
piece of jewelery, electrolysis and tattooing for cosmetic purposes. Other exceptions include
male circumcision as part of a religious tradition or ceremony, and taking a blood sample by a
person employed by a laboratory licensed under the laboratory and specimen collection centre
licensing act.
Initiation of controlled acts:
Regulations under the Nursing Act, 1991 give the authority to initiate specific controlled acts to
nurses who meet certain conditions. This means that these nurses may independently decide that
a specified procedure is required and initiate that procedure in the absence of a specific order or
medical directive from a physician. If initiating is within the scope of her/his role and
competence, the initiating RN may perform the procedure or may write the order for another
nurse to perform it; RPNs may initiate a procedure, but not write an order for another nurse to
perform the procedure. Safe, appropriate initiation of a procedure involves:
■ assessing the client and identifying a problem;
■ considering all the available options to address the problem;
■ weighing the risks and benefits of each option in light of the client’s condition;
■ deciding on a course of action; and
■ accepting sole accountability for deciding that the particular procedure is required and
ensuring that any potential consequences are managed appropriately
RNs or RPNs who are competent to do so may perform a procedure initiated (ordered) by an RN.
A nurse can initiate a procedure only when all of the following conditions are met:
■ the nurse has the knowledge, skill and judgment to perform the procedure safely, effectively
and ethically;
■ the nurse has the knowledge, skill and judgment to determine whether the client’s condition
warrants performance of the procedure;
■ the nurse determines that the client’s condition warrants performance of the procedure having
considered:
◗ the known risks and benefits to the individual,
◗ the predictability of outcomes of performing the procedure,
◗ the safeguards and resources available in the circumstances to safely manage the
outcomes of performing the procedure, and
◗ other relevant factors specific to the situation; and

■ the nurse accepts sole accountability for determining that the client’s condition warrants
performance of the procedure.
The following are the procedures that may be initiated (performed) by an RPN who meets the
conditions described above:
1. Care of a wound below the dermis or the mucous membrane by cleansing, soaking or
dressing.
2. For the purpose of assisting a client with health management activities, a procedure that
involves putting an instrument beyond the point in the client’s nasal passages where they
normally narrow, beyond the client’s larynx or beyond the opening of the urethra.
requires putting a hand or finger beyond the labia majora
4. For the purpose of assessing a client or assisting a client with health management activities, a
procedure that requires putting an instrument or finger beyond the anal verge.
memory that may seriously impair the individual’s judgement, insight, behaviour,
communication or social functioning.
The following are the procedures that may be initiated (performed and/or ordered) by an RN who
meets the conditions previously described:
1. Care of a wound below the dermis or the mucous membrane by cleansing, soaking, irrigating,
probing, debriding, packing or dressing.
2. Venipuncture to establish peripheral intravenous access and maintain patency using a solution
of normal saline (0.9 percent) when the client requires medical attention and delaying
venipuncture is likely to be harmful to the client. This permits an RN to establish intravenous
access in anticipation of treatment being prescribed imminently. The authorized procedure is
establishing the access, not using the solution as a form of treatment. Determining the solution
and rate of solution are not within the scope of RN practice.
involves putting an instrument beyond the point in the client’s nasal passages where they
normally narrow, beyond the client’s larynx or beyond the opening of the urethra.
4. For the purpose of assessing a client or assisting a client with health management activities, a
procedure that requires putting:
◗ an instrument or finger beyond the individual’s anal verge or into an artificial opening
into the client’s body; or
◗ an instrument, hand or finger beyond the individual’s labia majora.

NOTE: Procedures that involve putting an instrument or finger into one of the body openings, or
into an artificial opening of the body for the purposes of treating a health problem, cannot be
initiated by an RN. Authorized procedures are also limited to those activities that do not require
the use of a prescribed drug, as RNs in the General Class are not authorized to prescribe drugs.
NPs have additional controlled act authority as discussed in the next section.
Controlled acts authorized to NPs:
Nurse Practitioners have the authority to perform the following controlled acts:
1. Communicating to a client or a client’s representative, a diagnosis made by the NP identifying
as the cause of the client’s symptoms, a disease or disorder.
2. Performing a procedure below the dermis or a mucous membrane.
3. Puting 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
vii. into an artificial opening of the body.
4. Applying or ordering the application of a prescribed form of energy
6. 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.
7. Prescribing, dispensing, selling or compounding a drug in accordance with the regulation
communication or social functioning
Delegation:
Delegation is a formal process by which a regulated health professional, who is authorized and
competent to perform a procedure under one of the controlled acts, delegates the performance of
that procedure to someone, regulated or unregulated, who is not authorized by legislation to
perform it. There are controlled acts not authorized to nursing by the legislation, but which may
be performed by a nurse when the procedure has been delegated by a person who is authorized
by legislation to perform it. For information about nurses’ accountabilities in delegating
activities and accepting delegation, refer to the College’s Authorizing Mechanisms and Working
With Unregulated Care Providers practice documents.
Conclusion:
The RHPA scope of practice and controlled acts model provides a flexible framework that
facilitates the evolution of the nursing profession’s scope of practice. The College’s practice
document Decisions About Procedures and Authority assists nurses in making decisions about
the performance of procedures and in understanding their individual accountability
Legislation and Regulation: an introduction to the nursing act, 1991
● The Nursing Act, 1991, along with the Regulated Health Professions Act, 1991 (RHPA),
determines how the nursing profession is regulated in Ontario. The RHPA applies to all of
Ontario’s self-regulated health professions. The Nursing Act establishes the mandate of the
College of Nurses of Ontario and defines the scope of practice for the nursing profession. This
fact sheet explains how the Nursing Act regulates registration (for example, classes of
registration, entry-to-practice requirements, title protection), controlled acts (these are procedures
that can only be performed by an authorized healthcare professional), quality assurance and
professional misconduct.
Scope of practice for nursing:
Each profession has a scope of practice statement that describes what the profession does and the
methods it uses. The nursing scope of practice statement is: 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.
Registration categories and classes:
There are two categories of nurses: Registered Nurses (RNs) and Registered Practical Nurses
(RPNs). There are several classes within each category.
General Class — Most of the College’s RNs and RPNs are registered in this class.
Extended Class—RNs in this class are Nurse Practitioners (NPs). They have met additional
competency requirements beyond those required in the General Class. There are three specialty
certificates in the Extended Class: NP-Adult, NP-Paediatrics, NP-Primary Health Care (a fourth
specialty certificate, NP-Anaesthesia, is not available at this time).
Temporary Class — RNs and RPNs in this short-term class are recent graduates, or applicants
from outside the province, who have met all entry-to-practice requirements except successful
completion of the registration exam. They practise as an RN or RPN subject to specific terms.
Special Assignment Class — A short-term, nonrenewable registration for RNs and RPNs,
usually from outside of Canada, who have an appointment or assignment with an approved
facility in Ontario. They practise as an RN or RPN subject to specific terms.
Emergency Assignment Class — RNs and RPNs, usually from outside of Ontario, are registered
in this class when the provincial government has asked the College to issue certificates of
registration in this class.
Non-Practising Class — Available to current and previous members of the College’s General or
Extended classes, members in this class are not allowed to practice, or represent themselves as
qualified to practice, nursing in Ontario.
Entry to practice:
Applicants must meet certain requirements to register as nurses in Ontario. For example, to
register in the General Class, applicants must:
●successfully meet the nursing education requirement
●provide evidence of nursing practice
●successfully complete the national registration examination
●successfully complete the jurisprudence examination
●demonstrate they are proficient in either English or French
●provide proof of citizenship, permanent residency or authorization under the Immigration and
Refugee Protection Act (Canada) to engage in the practice of nursing in Ontario
●complete a Declaration of Registration Requirements form.
Title protection:
Titles used by nurses are protected under the Nursing Act. This means that, in Ontario, only
members of the College can use the titles of nurse, Registered Nurse Registered Practical Nurse,
or any variation, abbreviation or equivalent in another language. Only nurses in the Extended
Class can use the title Nurse Practitioner. Individuals who refer to themselves as nurses or
attempt to work as nurses in Ontario without being registered with the College are illegal
practitioners and can be prosecuted under the Nursing Act and RHPA.
Controlled acts authorized to nursing:
The RHPA lists 14 controlled acts that are considered potentially harmful if performed by
someone who isn’t qualified. The Nursing Act authorizes nurses to perform the following
controlled acts when ordered or permitted by the regulations pertaining to initiation:
●performing a prescribed procedure below the dermis or mucous membrane;
●administering a substance by injection or inhalation;
● putting an instrument, hand or finger:
vi. beyond the anal verge or
vii. into an artificial opening in the body.
●dispensing a drug.
●treating, by means of psychotherapy technique, delivered through a therapeutic relationship, an
individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or
Initiation of controlled acts by nurses
●The Nursing Act gives RNs and RPNs who meet certain conditions the authority to initiate
specific controlled acts. This means they may independently decide if a specific procedure is
required and safely initiate the procedure without a specific order or directive from a physician.
In some cases, the authority of RNs and RPNs to initiate may be limited by other legislation or
employer policies. For more information, refer to the College’s Decisions About Procedures and
Authority practice document.
Controlled acts authorized to NPs:
NPs have the authority 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 the client’s symptoms, a disease or disorder.
● performing a procedure below the dermis or a mucous membrane.
●putting an instrument, hand or finger:
●applying or ordering the application of a prescribed form of 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
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
Quality Assurance:
The RHPA requires that the College establish and operate a Quality Assurance (QA) Program
that assists nurses to maintain competence and continually evaluate their practice.
Professional misconduct regulations:
Professional misconduct for nurses is defined in the Nursing Act as an act or omission that
breaches accepted ethical and professional standards of conduct. For more information, refer to
the College’s Professional Misconduct document.
Professional Standards, Revised 2002
Nursing standards are expectations that contribute to public protection. They inform nurses of
their accountabilities and the public of what to expect of nurses. Standards apply to all nurses
regardless of their role, job description or area of practice. — College of Nurses of Ontario
Introduction:
● Professional Standards, Revised 2002 (Professional Standards) provides an overall framework
for the practice of nursing and a link with other standards, guidelines and competencies
developed by the College of Nurses of Ontario (CNO). It describes in broad terms the
professional expectations of nurses1 and applies to all nurses, in every area of practice.
●Professional Standards includes seven broad standard statements, a description of each
statement and indicators that illustrate how the standard may be demonstrated. To help nurses in
different practice areas apply the standards, there are indicators for all nurses and for those in
administrative, educational and research positions. As well, three of the standards (Knowledge,
Knowledge application and Leadership) have indicators for RNs and NPs.
●The indicators used in this document are not a complete list, nor do they apply to all nurses at
all times. As well, the seven standards are interrelated; an indicator used to illustrate one
standard may also demonstrate the application of other standards. How a nurse demonstrates a
standard is influenced by the nurse’s level of competence, role, practice setting and the situation.
It is expected that all nurses will meet the expectations of these professional standards and be
able to articulate how they demonstrate the standards in their practice.
Guiding principles:
The following principles guided the development of Professional Standards:
■ in Ontario, nursing is one profession with two categories — RN (which includes NPs) and
RPN;
■ the foundational knowledge base of RNs and RPNs is different because of differences in basic
nursing education;
■ all nurses are accountable for their own decisions and actions and for maintaining competence
throughout their career;
■ clients are the central focus of the professional services that nurses provide and as partners in
the decision-making process, clients ultimately make their own decisions;
■ the goal of professional practice is to obtain the best possible outcome for clients, with no
unnecessary exposure to risk of harm; and
■ all nurses continually enhance their knowledge through education, experience and self-
assessment. Nurses can become experts in an area of practice within their category.
●A standard is an authoritative statement that sets out the legal and professional basis of nursing
practice.
●All standards of practice provide a guide to the knowledge, skills, judgment and attitudes that
are needed to practise safely. They describe what each nurse is accountable and responsible for
in practice. Standards represent performance criteria for nurses and can interpret nursing’s scope
of practice to the public and other health care professionals. Standards can be used to stimulate
peer feedback, encourage research to validate practice and generate research questions that lead
to improvement in health care delivery. Finally, standards aid in developing a better
understanding and respect for the various and complementary roles that nurses have.
Standards: The seven standards are presented in alphabetical order. All standards have equal
importance and are interconnected.
1.Accountability: Each nurse is accountable to the public and responsible for ensuring that
her/his practice and conduct meets legislative requirements and the standards of the profession.
Indicators: A nurse demonstrates the standard by:
■ identifying her/himself and explaining her/his role to clients;
■ providing, facilitating, advocating and promoting the best possible care for clients;
■ advocating on behalf of clients;
■ seeking assistance appropriately and in a timely manner;
■ sharing nursing knowledge and expertise with others to meet client needs;
■ ensuring practice is consistent with CNO’s standards of practice and guidelines as well as
legislation;
■ taking action in situations in which client safety and well-being are compromised;
■ maintaining competence and refraining from performing activities that she/he is not competent
in;
■ taking responsibility for errors when they occur and taking appropriate action to maintain
client safety;
■ reporting to the appropriate authority any health care team member or colleague whose actions
or behaviours toward clients are unsafe or unprofessional, or indicate abuse, in accordance with
applicable legislation, including (but not limited to):
◗ the Long-Term Care Homes Act, 2007;
◗ the Child, Youth and Family Services Act, 2017;
◗ the Public Hospitals Act, and

■ reporting sexual abuse of a client by a regulated health professional to the appropriate
regulatory college, as legislated in the Regulated Health Professions Act, 1991.
In addition, a nurse in an administrator role demonstrates the standard by:
■ ensuring that mechanisms allow for staffing decisions that are in the best interest of clients
and professional practice;
■ ensuring the appropriate use, education and supervision of staff;
■ advocating for a quality practice setting that supports nurses’ ability to provide safe, effective
and ethical care; and
■ creating an environment that encourages ongoing learning.
A nurse in an educator role demonstrates the standard by:
■ ensuring the appropriate supervision of students;
■ communicating the level of preparation of the student and the objectives of the learning
experience;
■ using standards of practice and evidence-based knowledge to educate students; and
■ ensuring that nurses receive the appropriate education, support and supervision when acquiring
new knowledge and skills.
A nurse in a researcher role demonstrates the standard by:
■ ensuring the safety and well-being of the client above all other objectives, including the search
for knowledge.
2. Continuing Competence: Each nurse maintains and continually improves her/his competence
by participating in the College of Nurses of Ontario’s Quality Assurance (QA) Program.
●Competence is the nurse’s ability to use her/his knowledge, skill, judgment, attitudes, values
and beliefs to perform in a given role, situation and practice setting. Continuing competence
ensures that the nurse is able to perform in a changing health care environment. Continuing
competence also contributes to quality nursing practice and increases the public’s confidence in
the nursing profession.
●Participation in CNO’s QA Program helps nurses engage in activities that promote or foster
lifelong learning. The program helps nurses maintain and improve their competence and is a
professional requirement.
■ assuming responsibility for her/his own professional development and for sharing knowledge
with others;
■ investing time, effort and other resources to improve knowledge, skills and judgment;
■ engaging in a learning process to enhance her/his practice;
■ participating in the College’s QA Program. Participation includes:
◗ performing a self-assessment;
◗ seeking peer input;
◗ developing a learning plan;
◗ implementing the plan; and
◗ evaluating the outcomes of the plan;

■ keeping records of participation in QA Program activities;
■ providing colleagues with feedback that encourages professional growth;
■ participating in Practice Assessment when selected;
■ advocating for quality practice improvements in the workplace; and
■ working together to create quality practice settings that promote continuing competence.
■ supporting nurses to become reflective practitioners;
■ encouraging nurses to engage in ongoing learning;
■ seeking opportunities for nurses to participate in continual learning activities;
■ seeking opportunities to incorporate reflective practice into agency professional development
systems; and
■ advocating for a quality practice setting.
■ supporting students and nurses in becoming reflective practitioners;
■ developing, implementing and facilitating learning activities that help nurses enhance their
practice; and
■ supporting nurses in engaging in ongoing learning.
■ encouraging the evaluation of practice through research; and
■ communicating best-practice research findings to others.
3. Ethics: Each nurse understands, upholds and promotes the values and beliefs described in
CNO’s Ethics practice standard.
●Ethical nursing care means promoting the values of client well-being, respecting client choice,
assuring privacy and confidentiality,5 respecting the sanctity and quality of life, maintaining
commitments, respecting truthfulness and ensuring fairness in the use of resources. It also
includes acting with integrity, honesty and professionalism in all dealings with the client and
other health care team members.
■ identifying ethical issues and communicating them to the health care team;
■ identifying options to resolve ethical issues;
■ evaluating the effectiveness of the actions taken to resolve ethical issues; and
■ identifying personal values and ensuring they do not conflict with professional practice.
■ creating environments that promote and support safe, effective and ethical practice;
■ valuing the time that’s taken to resolve ethical issues;
■ advocating for resources and establishing mechanisms to assist nurses in recognizing and
resolving ethical issues;
■ supporting nurses in developing skills to recognize and manage ethical issues; and
■ facilitating/advocating for nursing input on ethics committees.
■ encouraging and supporting critical thinking and dialogue about ethical issues; and
■ assisting nurses and students in identifying resources to improve recognition and resolution of
ethical issues.
■ ensuring that the client has all the information necessary to make informed decisions;
■ advocating for nursing involvement on ethical review boards;
■ participating in the ethical review of research; and
■ ensuring ethical guidelines are followed to protect research participants.
4. Knowledge: Each nurse possesses, through basic education and continuing learning,
knowledge relevant to her/ his professional practice.
●RNs, RPNs and NPs study from the same body of nursing knowledge. RPNs study for a shorter
period of time than RNs and NPs. They have a more focused or basic foundation of knowledge
in clinical practice, decision-making, critical thinking, research and leadership. RNs and NPs
study for a longer period of time to achieve a greater breadth and depth of knowledge in clinical
practice, decision-making, critical thinking, research utilization, leadership, health care delivery
systems and resource management. All nurses add to their basic education and foundational
knowledge by pursuing ongoing learning throughout their careers.
■ providing a theoretical and/or evidence-based rationale for all decisions;
■ being informed and objective about the various nursing roles and their relationship to one
another;
■ being informed about nursing and its relationships in the health care delivery system;
■ understanding the legislation and standards relevant to nursing and the practice area;
■ understanding the knowledge required to meet the needs of complex clients;
■ having knowledge of how bio-psychosocial needs and cultural background relate to health care
needs;
■ knowing where/how to access learning resources, when necessary;
■ seeking and reviewing research in nursing, the health sciences and related disciplines;
■ using research to inform practice/professional service; and
■ being aware of how practice environments affect professional practice. In addition, an RN or
NP demonstrates the standard by:
■ contributing to the generation of new professional knowledge through research;
■ seeking and critiquing philosophical, theoretical and research-based literature in nursing,
health care services, etc.; and
■ using philosophy, theory and research to inform practice.
A nurse in an administrator role demonstrates the standard by:
■ understanding how a practice environment can foster professional growth and improve
professional practice;
■ facilitating nurses to continually seek new knowledge;
■ knowing how to access resources to enable nurses to provide the best possible care;
■ critically evaluating research related to outcomes and advocating for its application in practice;
■ using relevant leadership and management principles; and
■ understanding and promoting nursing as as knowledge-based and research-informed
profession.
■ identifying and evaluating information sources that are useful for professional practice;
■ promoting an environment that facilitates questioning and learning; and
■ possessing/developing knowledge of teaching learning theories and practices.
■ identifying research methods useful to the nursing profession;
■ identifying resources to answer research questions; and
■ sharing knowledge gained through research.
5. Knowledge Application: Each nurse continually improves the application of professional
knowledge.
●The quality of professional nursing practice reflects nurses’ application of knowledge. Nurses
apply knowledge to practice using nursing frameworks, theories and/or processes. They employ
knowledge in the performance of clinical skills because the technical and cognitive aspects of
care are closely related and cannot be separated.
Indicators A nurse demonstrates the standard by:
■ ensuring that practice is based in theory and evidence and meets all relevant standards/
guidelines;
■ assessing/describing the client situation using a theory, framework or evidence-based tool;
■ identifying/recognizing abnormal or unexpected client responses and taking action
appropriately;
■ recognizing limits of practice and consulting appropriately;
■ planning approaches to providing care/service with the client;
■ creating plans of care that address client needs, preferences, wishes and hopes;
■ using best-practice guidelines to address client concerns and needs;
■ managing multiple nursing interventions simultaneously;
■ evaluating/describing the outcomes of specific interventions and modifying the plan/approach;
■ identifying and addressing practice-related issues; and
■ integrating research findings into professional service and practice.
In addition, an RN or NP demonstrates the standard by:
■ analyzing and applying a wide range of information using a variety of frameworks or theories
that result in a global approach and creative solutions;
■ anticipating and preparing for possible outcomes by analyzing all influences;
■ identifying a full range of options based on a depth and breadth of knowledge;
■ creating comprehensive and creative plans of care that reflect the complexity of client needs;
■ meeting client needs regardless of complexity and predictability;
■ analyzing and interpreting unusual client responses; and
■ evaluating theoretical and research-based approaches for application to practice.
■ creating practice environments that support quality nursing practice;
■ establishing and maintaining communication systems to support quality service and research;
■ supporting and contributing to practice environments that encourage learning, and the
application of nursing knowledge and research; and
■ articulating an evidence base for all decisions and measuring the impact on practice.
■ planning and implementing creative learning opportunities for students/nurses;
■ critically analyzing and evaluating nursing practice and education; and
■ creating an environment where learning is encouraged.
■ supporting and evaluating practice through research;
■ facilitating the involvement of others in the research process;
■ ensuring that high standards are used in the research process;
■ communicating research findings to decisionmakers and others;
■ supporting and contributing to environments that encourage the application of research
findings to professional practice;
■ securing resources to explore nursing research; and
■ fostering an atmosphere of inquiry
6. Leadership: Each nurse demonstrates her/his leadership by providing, facilitating and
promoting the best possible care/service to the public.
●Leadership requires self-knowledge (understanding one’s beliefs and values and being aware of
how one’s behaviour affects others), respect, trust, integrity, shared vision, learning,
participation, good communication techniques and the ability to be a change facilitator.7 The
leadership expectation is not limited to nurses in formal leadership positions. All nurses,
regardless of their position, have opportunities for leadership.
Indicators A nurse demonstrates the standard by:
■ role-modelling professional values, beliefs and attributes;
■ collaborating with clients and the health care team to provide professional practice that
respects the rights of clients;
■ advocating for clients, the workplace and the profession;
■ providing direction to, collaborating with, and sharing knowledge and expertise with novices,
students and unregulated care providers;
■ acting as a role model and mentor to less experienced nurses and students;
■ participating in nursing associations, committees and interest groups;
■ providing leadership through formal and informal roles (e.g., team leader, charge nurse);
■ taking action to resolve conflict; and
■ developing innovative solutions to practice issues.
In addition, an RN or NP demonstrates the standard by:
■ coordinating care for complex clients and demonstrating leadership when collaborating with
care providers.
■ identifying goals that reflect CNO’s mission and values and facilitate the advancement of
professional practice;
■ guiding/coaching nursing projects;
■ providing feedback and support to staff about nursing issues at an individual and
organizational level;
■ creating opportunities for nurses to assume various leadership roles;
■ involving nursing staff in decisions that affect their practice; and
■ coordinating and supervising the development of client programs and services.
■ role-modelling the development of expertise and leadership qualities;
■ enabling others to develop expertise and confidence in their abilities; and
■ providing professional and educational advice to committees and teams.
■ communicating research findings to nurses and other team members;
■ promoting nursing research;
■ educating staff about the research process;
■ promoting nursing through research that improves or validates professional practice; and
■ advocating for nursing representation on research review committees.
7. Relationships: Each nurse establishes and maintains respectful, collaborative, therapeutic and
professional relationships.
● Relationships include therapeutic nurse-client relationships and professional relationships with
colleagues, health care team members and employers.
Therapeutic Nurse-Client Relationships The client’s needs are the focus of the relationship,
which is based on trust, respect, intimacy and the appropriate use of power.9 Nurses demonstrate
empathy and caring in all relationships with clients, families and significant others. It is the
responsibility of the nurse to establish and maintain the therapeutic relationship.
■ practising according to CNO’s Therapeutic NurseClient Relationship, Revised 2006 practice
standard;
■ demonstrating respect and empathy for, and interest in clients;
■ maintaining boundaries between professional therapeutic relationships and non-professional
personal relationships;
■ ensuring clients’ needs remain the focus of nurseclient relationships;
■ ensuring that her/his personal needs are met outside of therapeutic nurse-client relationships;
■ developing collaborative partnerships with clients and families that respect their needs,
wishes, knowledge, experience, values and beliefs;
■ recognizing the potential for client abuse;
■ preventing abuse when possible; and
■ taking action to stop abuse and reporting it appropriately
■ fostering an environment in which clients and nurses are safe from abuse;
■ supporting the therapeutic nurse-client relationship;
■ promoting a philosophy of client-centred care and collaborative relationships; and
■ advocating for systems of care that acknowledge and support nurses in developing and
maintaining therapeutic relationships.
■ role-modelling therapeutic nurse-client relationships; and
■ identifying and supporting education related to professional and therapeutic relationships.
■ communicating knowledge of evidence-based, best-practice guidelines related to caring and
therapeutic relationships.
Professional Relationships: Professional relationships are based on trust and respect, and result in
improved client care.
■ role-modelling positive collegial relationships;
■ using a wide range of communication and interpersonal skills to effectively establish and
maintain collegial relationships;
■ demonstrating knowledge of and respect for each other’s roles, knowledge, expertise and
unique contribution to the health care team;
■ sharing knowledge with others to promote the best possible outcomes for clients;
■ developing networks to share knowledge of best practices; and
■ demonstrating effective conflict-resolution skills.
■ promoting a work environment in which trust and respect among all health care disciplines is
expected;
■ ensuring systems are in place to effectively reduce and manage conflict between team
members;
■ supporting nurses to take action when clients are at risk of harm from colleagues; and
■ valuing and acknowledging nursing expertise and contributions to the health care of clients.
■ facilitating the development of conflict-resolution skills; and
■ supporting nurses in developing skills to address any unethical, unprofessional or unsafe
behaviour of colleagues.
■ communicating knowledge of the research process and relevant studies to other nurses and
team members; and
■ supporting nurses in participating in research studies.
DOS: Professionhood week 2 CNO code of conduct
●To help do this, we’ve created a Code of Conduct (Code) to explain the behaviour you, the
public, can expect of nurses when receiving health care. All nurses are accountable to this Code.
●The Code consists of six principles:
1. Nurses respect the dignity of patients and treat them as individuals
2. Nurses work together to promote patient well-being
3. Nurses maintain patients’ trust by providing safe and competent care
4. Nurses work respectfully with colleagues to best meet patients’ needs
5. Nurses act with integrity to maintain patients’ trust
6. Nurses maintain public confidence in the nursing profession.
Principle 1: Nurses respect the dignity of patients and treat them as individuals:
1.1 Nurses treat patients with care and compassion.
1.2 Nurses show respect to patients’ culture, identity, beliefs, values and goals.
1.3 Nurses take steps to maintain patients’ privacy and dignity in the physical space where they
are receiving care.
1.4 Nurses listen and collaborate with patients and any person the patients want involved in their
care.
1.5 Nursing care is not judgmental and is free of discrimination.
1.6 Nurses reflect on and address their own practice and values that may affect their nursing care.
1.7 Nurses do not impose their personal beliefs and biases on patients. These include political,
religious and cultural beliefs. If they see other health care team members doing this, nurses
intervene.
1.8 When a nurse’s own personal beliefs conflict with a patient’s care plan, the nurse provides
safe, compassionate and timely care to those patients, until other arrangements are in place
Principle 2: Nurses work together to promote patient well-being:
2.1 Nurses provide clear and timely information to patients. Nurses talk to patients in ways
patients understand, inviting their feedback.
2.2 Nurses strive to meet patients’ language and communication needs.
2.3 Nurses show respect for patients’ rights and involve patients in making care decisions.
2.4 Nurses ask for consent from appropriate decision-makers when patients are unable to do so.
2.5 Nurses acknowledge patients’ right to express concerns. Nurses respond by working with
patients to resolve concerns.
2.6 Nurses advocate for patients and help them access appropriate health care.
2.7 Nurses understand there may be gaps impacting patient care and health outcomes in some
communities. They work together with health care teams to address these gaps.
2.8 Nursing care is timely. When this is not possible, nurses explain the reasons for this delay to
patients.
Principle 3: Nurses maintain patients’ trust by providing safe and competent care:
3.1 Nurses identify themselves, their first name, last name, title and their role to patients.
3.2 Nurses use appropriate knowledge, skill and judgment when assessing the health needs of
patients.
3.3 Nurses respond and are available to patients when working.
3.4 Nurses recognize and work within the limits of their knowledge, skill and judgment and their
legal scope of practice.
3.5 Nurses seek advice and collaborate with the health care team to uphold safe patient care.
3.6 Nurses maintain and continually improve their competence (a nurse’s ability to consistently
apply the required knowledge, skill and judgment for safe, ethical and effective nursing practice).
They reflect on their practice and set learning goals annually by participating in CNO’s Quality
Assurance Program.
3.7 Nurses use accurate sources of information, such as research, to inform their practice.
3.8 Nurses maintain complete, accurate and timely documentation in their practice.
3.9 Nurses are accountable to, and practice under, relevant laws and CNO’s standards of
practice (CNO’s expectations for how a competent nurse should perform. Standards of practice
contribute to public protection).
Principle 4: Nurses work respectfully with colleagues to best meet patients’ needs:
4.1 Nurses are professional with colleagues and treat them with respect, including on social
media.
4.2 Nurses collaborate and communicate with colleagues in a clear, effective, professional and
timely way.
4.3 Nurses work together with other health care experts to improve their patients’ care.
4.4 Nurses support, mentor and teach members of the health care team, including students.
4.5 Nurses take action to stop unsafe, incompetent, unethical or unlawful practice, including any
type of abuse
Principle 5: Nurses act with integrity to maintain patients’ trust:
5.1 Nurses protect the privacy and confidentiality of patients’ personal health information.
5.2 Nurses do not share patient information on social media.
5.3 Nurses take prompt action to prevent and protect patients from harm.
5.4 Nurses do not accept gifts from patients, unless it harms the professional relationship with
patients.
5.5 Nurses do not act as powers of attorney or substitute decision-makers for patients.
5.6 Nurses declare any conflict of interest that could affect their judgment. This includes a
nurse’s personal, financial or commercial interest.
5.7 Nurses maintain integrity. They do not use their position to promote or sell products for
personal gain.
5.8 Nurses maintain professional boundaries with patients.
5.9 Nurses do not engage in any sexual relationship with patients while caring for them. This law
stays in effect for one year after the end of the nurse-patient relationship.
Principle 6: Nurses maintain public confidence in the nursing profession:
6.1 Nurses are accountable for their own actions and decisions.
6.2 Nurses respect the property of their patients and employers.
6.3 Nurses clearly communicate to patients the details of care or a service they intend to provide.
6.4 Nurses advocate for improving the quality of their practice setting to support safe patient
care.
6.5 Nurses have a duty to report any error, behaviour, conduct or system issue that affects
patient safety. 6.6 Nurses do not practice when impaired by any substance.
6.7 Nurses are responsible for maintaining their health. They seek help if their health affects their
ability to practice safely.
Slides:
●ETP Competencies for RN
• Tommy Douglas
1947 • Public universal hospital insurance plan;
Sask
• All provinces covered inpatient hospital

1961 care
• All provinces extended coverage to medical

1972 services outside of hospitals
• Canada Health Act

1984
• Indian Act – federal government’s role in
1985 provision of health for Indigenous
population
Canadian Health Care Act (1984): Principles:
1. Universality: all eligible residents are entitled to public health insurance coverage on
uniform terms and conditions;
2. Portability: coverage for insured services must be maintained when an insured person
moves or travels within Canada or travels outside the country;
3. Public administration (publically funded): the health insurance plan of a province or
territory must be administered on a non-profit basis by a public authority;
4. Accessibility: reasonable access by insured persons to medically necessary hospital and
physician services must not be impeded by financial or other barriers, and
5. Comprehensiveness: all medically necessary services provided by hospitals and doctors
must be insured.
Health care structure
Ministry of
Federal Health/
Health Canada
Ministry of
Provincial Health & Long
Term Care
Local Health
Integration Public Health
Networks
Hospitals – Community –
Long term Care; Primary
Care
Ontario Health Team-integrated care delivery systems

World Health Organization (WHO):
●WHO works worldwide to promote health, keep the world safe, and serve the vulnerable.
●The goal is to ensure that a billion more people have universal health coverage, to protect a
billion more people from health emergencies, and provide a further billion people with better
health and well-being.
Care Continuum:
•Personal health
Primary Health Primary Care Secondary Care Tertiary Care
services
Care
•1st point of
contact with •Aims to soften
•Aims to prevent •Aims to reduce the impact of
disease or health system the impact of a an ongoing
injury before it disease or illness or injury
ever occurs injury that has that has lasting
•Screening, already effects
prevention, occurred
•Specialized care
emergency •Treatment for
services, •Rehab
short term
education and acute illness, •Oncology
health injury •Teaching
promotion •Hospital or hospitals
home care
Levels of Care: nursing roles
Health
Promotion
Disease and
Supportive
injury
Care
prevention
Diagnosis and
Rehabilitation Treatment
smoking
cessation program-health promotion, mandatory to wear a helmet-injury prevention
Nursing Associations/ Organizations:
●Registered Nurses Association of Ontario
●College of Nurses of Ontario
●The International Council of Nurses (ICN) is a federation of more than 130 national nurses’
associations (NNAs), representing the more than 16 million nurses worldwide. Founded in 1899,
ICN is the world’s first and widest reaching international organization for health professionals.
Operated by nurses and leading nurses internationally, ICN works to ensure quality nursing care
for all, sound health policies globally, the advancement of nursing knowledge, and the presence
worldwide of a respected nursing profession and a competent and satisfied nursing workforce.
●Canadian Nurses Protective Society
●Registered Practical Nurses Association of Ontario
●Canadian Nurses Association
●Ontario Nurses Association
●World Health Organization
Nursing Care Delivery Models
Telepractice
Task Team
Oriented Nursing
Total Patient Primary

Care Nursing
Modular
Nursing
Impact on Patient Outcomes

●Medication errors
●Falls
●Length of stay
●Patient Satisfaction
Impact of Nurse Outcomes
●Role clarity
●Communication
Organizational Outcomes
●Cost
Week 3: CNO Refusing Assignments and Discontinuing Nursing Services

● Standards: 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, Revised 2002: This document describes in broad terms the
professional expectations for all nurses in every area of practice.
●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.
Ethics:
●Nurses demonstrate regard for client well-being and maintain commitments by:
■ using their knowledge and skill to promote clients’ best interests in an empathetic manner;
■ putting the needs and wishes of clients first;
■identifying when their own values and beliefs conflict with the ability to keep implicit and
explicit promises and taking appropriate action;
■ advocating for quality client care; and
■ making all reasonable efforts to ensure that client safety and well-being are maintained during
any job action.
NOTE: The Ethics document informs nurses of the need to recognize and function within their
own value system, and the need to work collaboratively with colleagues and promote an
environment of collegiality.
Legislation:
The Nursing Act, 1991 includes regulations3 that define professional misconduct. Some of the
definitions of professional misconduct may be relevant in situations in which nurses refuse
assignments or discontinue nursing services. Although there is no specific definition of
professional misconduct that includes the word abandonment, the definitions can guide nurses on
what might constitute professional misconduct related to refusing an assignment or discontinuing
nursing services.
The relevant definitions of professional misconduct in the legislation are found in the following
clauses. 1 (1) Contravening a standard of practice of the profession or failing to meet the
standard of practice of the profession
1 (4) 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
1 (5) Discontinuing professional services that are needed unless:
i. the client requests the discontinuation,
ii. ii. alternative or replacement services are arranged, or
iii. iii. the client is given reasonable opportunity to arrange alternative or replacement
services
1 (29) Failing to fulfil the terms of an agreement for professional services
1 (37) 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
Refusing assignments:
●Refusing to work an extra shift or overtime is not the type of situation that was intended by the
inclusion of clause 1 (5) (discontinuation of services) in the Nursing Act as a definition of
professional misconduct; therefore, it is not considered abandonment. However, depending on
the context and facts of a particular situation, nurses can be found guilty of professional
misconduct under one of the other clauses.
Discontinuing nursing services:
Abandonment occurs when a nurse has accepted an assignment and discontinues care
without:
■ the client requesting the discontinuation;
■ arranging a suitable alternative or replacement service; or
■ allowing a reasonable opportunity for alternative or replacement services to be provided.
NOTE: A nurse who discontinues services without meeting the above conditions could be found
guilty of professional misconduct.
Guidelines for Decision-Making:
●Resolving dilemmas caused by conflicting obligations requires the thoughtful consideration of
all relevant factors and the use of an ethical decision-making process to ensure that the best
decision is reached. Sometimes there is no one best solution, but only the best of two or more
imperfect solutions.
●Collaboration, respectful behaviour and collegial communication among everyone in the
nursing and health team contribute to positive outcomes for clients and prevent problems from
arising in determining how nursing services are to be delivered.
●Communication is integral to all aspects of issue resolution. Communicating before a situation
develops will prevent or minimize risks to clients. It is important that nurses advocate for
appropriate staff and for planning for work stoppages.
Underlying principles:
The following principles guide the nurse’s decisions and actions when faced with situations in
which she/he is considering refusing an assignment or discontinuing services:
■ The safety and well-being of the client is of primary concern.
■ Critical appraisal of the factors in any situation is the foundation of clinical decision-making
and professional judgment.
■ Nurses are accountable for their own actions and decisions and do not act solely on the
direction of others.
■ Nurses have the right to refuse assignments that they believe will subject them or their clients
to an unacceptable level of risk (College of Nurses of Ontario, 2003, p. 9).
■ Nurses are not required to work extra shifts or overtime for which they are not contracted.
■ Individual nurses and groups of nurses’ safeguard clients when planning and implementing
any job action (Canadian Nurses Association, 2002, p. 22).
■ Persons whose safety requires ongoing or emergency nursing care are entitled to have these
needs satisfied throughout any job action (Canadian Nurses Association, 2002, p. 22).
Key expectations:
In choosing the appropriate course of action, nurses are expected to do the following:
■ Carefully identify situations in which a conflict with her/his own values interferes with the
care of clients (College of Nurses of Ontario, 2004b, p. 10) before accepting an assignment or
employment.
■ Identify concerns that affect her/his ability to provide safe, effective care.
■ Communicate effectively to resolve workplace issues.
■ Become familiar with the collective agreement or employment contract relevant to her/his
settings and take this into account when making decisions.
■ Learn about other legislation relevant to her/his practice setting.
■ Give enough notice to employers so that client safety is not compromised.
■ Provide essential services in the event of a strike.
■ Inform the union local and employer in writing of her/his ongoing professional responsibility
to provide care, which will continue in the event of any job action (for example, strike or
lockout).
Decision-making process:
●This diagram illustrates the process a nurse should take to resolve dilemmas related to
conflicting obligations. Some actions are short term, while others are proactive and long term.
No attempt has been made to identify all possible actions.
●The process includes four cyclical components. The process can begin at any point, but the best
outcome requires consideration of all of the components:
1. Identify issues, values, resources and conflicting obligations
2. Identify the options and develop a plan/approach
3. Implement the plan
4. Review, discuss and evaluate the process
1: Identify the issues, values, resources and conflicting obligations:
a) Have you previously agreed to accept the shift/ assignment?
b) What are the conflicting obligations, beliefs and values? Sometimes talking to others (for
example, a colleague, manager, College Practice Consultant) can help identify the values.
c) What are your values and emotions as they relate to the situation? Are they influencing your
ability to think clearly?
d) Have you gathered the facts of the situation from credible sources?
e) How have similar situations been handled in the past and what were the implications? Is there
an organizational policy or relevant legislation in place?
f) How will the care of the clients be affected if you leave?
g) What are the specific nursing care needs and priorities of the clients?
2: Identify the options and develop a plan/ approach:
a) Identify possible alternatives or solutions other than refusing the assignment or discontinuing
a service. Are other resources available (for example, protective equipment or expert resources)?
Can you ask the administrators for help?
b) Identify the risks and benefits for clients, nurses and others associated with each solution.
How can those risks be minimized?
c) Prioritize client care needs. Consult institutional policy/process, if available.
d) Identify all available resources and various options to ensure staffing is appropriate to meet
essential client care needs. For example, can you stay for a short time beyond the end of your
shift, or can someone come in early for the next shift?
e) Consider modifying the existing plan of care temporarily so the remaining staff can focus on
essential care needs, monitor the client(s) for changes in condition and act appropriately.
f) Weigh the options and decide on an approach.
g) Communicate to the appropriate person(s) the details of the problem and the planned solution
3: Implement the plan:
a) If you decide to leave, ensure that the remaining staff are aware of immediate and essential
client care needs.
b) If you stay to provide care, monitor ongoing client care priorities and your own ability to
practice safely.
c) Document (for example, in professional responsibility forms, incident reports or personal
notes) your decision, rationale and action taken. Include the date, time, who you communicated
with and actions taken to safeguard the client(s). Keep a copy for yourself and give one to your
employer and one to your risk manager.
d) Document the care provided and any unmet client needs on the client record. Communicate
outstanding care needs to the appropriate person.
e) When floating to other practice areas, agree to provide only aspects of care for which you are
competent (for example, vital signs, medication administration).
4: Review, discuss and evaluate the process:
a) When the immediate crisis is over, review the effectiveness of the decision/action (for
example, the outcomes).
b) Collaborate to plan strategies to prevent and/or manage similar situations in the future.
c) Develop strategies to solve ongoing safety issues. Strategies may involve literature reviews,
advocacy, etc.
d) Express ongoing concerns about staffing from the perspective of the impact on client care and
safety.
Maintaining a Quality Practice Setting:
● Quality nursing care includes safe and effective planning for staffing and job actions. As
partners in care, employers and nurses have a shared responsibility to create environments that
support quality practice.
●The College encourages practice settings to incorporate the following strategies to develop and
maintain a quality practice setting that helps nurses provide safe, effective, and ethical care. The
strategies also minimize situations in which nurses consider refusing assignments or
discontinuing services.
●All nurses are accountable for taking action in situations in which client care is compromised.
This accountability includes identifying and advocating for strategies to minimize and resolve
situations that could result in clients being left without needed nursing services. Nurse managers
and administrators can demonstrate leadership by advocating for and implementing the following
strategies.
Care delivery processes:
■ Implement care delivery models that meet the needs of clients and families as well as the
professional needs of staff.
■ Reorganize care providers, units and clients to provide for the complexity of care needs and
facilitate the safe delivery of care.
■ Structure the environment to provide the most efficient method of care provision (for example,
ready access to supplies).
Leadership:
■ Involve staff nurses in generating ideas for interim and long-term solutions, including
recruitment and retention.
■ Ensure that a system is in place to contact replacement staff readily (for example, on-call
system).
■ Develop strategies for prioritizing client care needs to facilitate the reorganization of
workload, if needed.
■ Develop clear lines of communication for nurses to follow when staffing is short.
■ Support nurses’ professional judgment and decision-making regarding strategies to meet the
needs of clients.
■ Recognize the professional accountability of nurses to refrain from practicing when they are
not able to provide safe care.
■ Continually evaluate the staffing situation to differentiate between trends and episodic
occurrences as each may require different strategies/approaches.
Organizational supports:
■ Provide a safe environment for nurses and clients.
■ Provide staffing that promotes the safety and well-being of clients.
■ Develop clear policies related to what nurses need to do before leaving their shift if relief staff
does not arrive.
■ Advocate for nurses’ involvement in the development of negotiated essential services
agreements.
Communication:
■ Facilitate goal-directed communication with challenging clients, families, colleagues and other
health care professionals (includes education and role modelling).
■ Provide communication systems that are readily available to contact replacement staff (for
example, cell phones and pagers).
■ Communicate with staff to identify circumstances that might influence their decision-making
in situations involving a high level of personal risk.
■ Develop clear communication processes for sharing updated information quickly in the event
of critical incidents.
■ Ensure that critical incident debriefing and conflict resolution mechanisms are in place.
Complaints about Nurses’ Practice:
●The College is required to investigate all formal complaints in which a nurse and the
complainant are clearly identified. These include complaints of refusing assignments and
discontinuing nursing services. All information relevant to the complaint is obtained, and the
nurse has an opportunity to respond to the allegations. All information, including any written
documentation that demonstrates the nurse’s effort to advocate and her/his problem-solving
rationale, is considered by the Inquiries, Complaints and Reports Committee (ICRC) before a
decision is made about what action, if any, should be taken.
●The College may also initiate an investigation into a nurse’s practice without a formal
complaint if there are reasonable and probable grounds to believe that the nurse has committed
an act of professional misconduct (for example, from information obtained through an
employer’s report of termination). These investigations are reviewed by the ICRC, which may,
when warranted, refer a case to the Discipline Committee for hearing. Any action taken by the
College through the discipline hearing process about a nurse’s registration is separate from any
action initiated by an employer, the government or the courts.
CNO: Disagreeing with the Care Plan

● Q: I work as an in-patient surgical unit nurse. Recently I cared for a patient and did not agree
with the patient’s care plan. What are my accountabilities when this happens? Am I obligated to
follow all patient orders?
A: All nurses, in all roles and practice settings are responsible for their actions and resulting
consequences. As self-reflective and regulated health professionals, a nurse’s clinical judgment
or critical thinking skills are always applied in assessing an order.
●Nurses who disagree with or are concerned about implementing a care plan are responsible for
following appropriate channels and conducting themselves in ways that promote respect for the
profession. In situations compromising patient safety and well-being, a nurse is primarily
responsible to the patient. A nurse demonstrates leadership by promoting best possible patient
care and taking appropriate action in situations they have identified as unsafe.
● When nurses disagree about what constitutes safe, ethical care they must assess the situation,
incorporate best available evidence, consult with key stakeholders and communicate with the
most responsible health care provider (for example, physician or NP) and other relevant team
members. These actions are key when demonstrating nurses’ accountability to share nursing
knowledge with others and in advocating on behalf of patients to promote best possible
outcomes.
● Resolving dilemmas caused by conflicting obligations requires thoughtful consideration of all

relevant factors and using an ethical decision-making process to reach the best decision. Nurses
must consider relevant CNO practice standards and guidelines and organizational policies and
guidelines. Also, nurses must identify key decision-makers, understand risks associated with the
questioned activity, take into account the patient’s beliefs and examine personal beliefs and
values, as applicable.
When disagreeing with a patient’s care plan, the following reflective questions may help guide
your decision-making:
▪ What are my specific concerns about the patient’s care plan?
▪ What evidence am I applying to the situation?

▪ Have I consulted with other nursing colleagues, experts and other health care
professionals to verify the concerns? What are the results?
▪ Have I discussed my concerns with relevant leadership team members?
▪ Have I advocated for additional support in resolving the issue?
▪ Am I aware of, and following, relevant organizational policies applying to the patient
situation?
▪ Am I aware of, and following, relevant organizational policies applying to resolving

disagreements?
▪ Have I consulted with management authority? (that is, quality and risk, professional
practice leaders)
▪ Have I communicated my decision to not implement the care plan?

▪ Do I understand the risks when doing so?
▪ Have I documented specific concerns and steps taken to resolve the issue?
Nurses are accountable for maintaining respectful and collaborative professional relationships
and demonstrating effective conflict-resolution skills. However, if unable to resolve the issue and
you decide to refuse to implement any aspect of the patient’s care plan, you are accountable for
communicating your decision effectively to minimize patient risks. This involves documenting
concerns and specific steps taken directly relating to patient care into the patient record.
Complete documentation of nursing care provided and all nursing process aspects, including
assessment, planning, intervention and evaluation is required.
CNO PRACTICE STANDARDS ETHICS

● The behavioural directives are intended to help nurses work through ethical situations and
provide information about the College of Nurses of Ontario’s (CNO’s) expectations for ethical
conduct. These are taken into account when CNO Committees assess nurses’ practices. Nurses
need to consider behavioural directives carefully when making decisions about ethical care as
this process will strengthen their practice.
Definitions:
●Nursing: Nursing is the therapeutic relationship that enables the client to attain, maintain or
regain optimal function by promoting the client’s health through assessing, providing care for
and treating the client’s health conditions. This is achieved by supportive, preventive,
therapeutic, palliative and rehabilitative means. The relationship with an individual client may be
a direct practice role or it may be indirect, by means of management, education or research roles.
●Therapeutic relationship: The therapeutic relationship is established and maintained by the
nurse through the nurse’s use of professional nursing knowledge, skill, and caring attitudes and
behaviours to provide nursing services that contribute to the client’s health and well-being. The
relationship is based on trust, respect and intimacy and requires the appropriate use of the power
inherent in the care provider’s role. (For further information, see CNO’s Therapeutic Nurse-
Client Relationship, Revised 2006 practice standard.)
●Caring: In the literature, caring is defined in a number of different ways (Fry, 1994). Caring can
be considered the behaviours, actions and attributes of nurses. Caring nurses listen to and are
empathetic with clients’ points of views. Generally, caring requires the recognition of clients as
unique individuals whose goals nurses facilitate. Clients’ values and choices are of primary
consideration when planning and providing care, and a nurse’s own personal values must never
interfere with the clients’ right to receive care.
●A client is a person or persons with whom the nurse is engaged in a professional therapeutic
relationship. In most circumstances, the client is an individual but in some circumstances (for
example, in practice settings where family-centred care occurs) the client can include family
members and/or substitute decision-makers of the individual client. The client may also be a
family, a group (for example, therapy) or a community (for example, public health). In
education, the client may be a student; in administration, the client may be staff; and in research,
the client is a subject or a participant (RNABC, 1998). Regardless of the role, whether directly or
indirectly involved with individual clients, all nurses are responsible for providing ethical care or
service within CNO standards
●Health care team: Health care, including nursing care, is usually provided within the context of
an interprofessional health care team. The individuals in the health care team are either directly
or indirectly involved in the client’s care. Depending on the setting, the composition of the team
will vary. The team includes the client or substitute decision-maker, and the client’s family
and/or significant other(s).
●The practice setting: When providing care, nurses consider the setting in which care is given.
Each setting has an impact on the ability to provide ethical care. Quality practice settings create
and maintain characteristics that support professional nursing practice, including appropriate
professional preparation, suitable conditions for nursing practice, respect for nurses as
responsible decision-makers, and recognition of professional expertise.
Ethical Values:
CNO has identified the following values as being most important in providing nursing care in
Ontario:
■ client well-being;
■ client choice;
■ privacy and confidentiality;
■ respect for life;
■ maintaining commitments;
■ truthfulness; and
■ fairness.
Types of ethical concerns:
●When two or more ethical values apply to a situation, but these values support diverging
courses of action, an ethical conflict or dilemma exists. Nurses may experience ethical
uncertainty when faced with a situation in which they are unsure of what values apply or even
where the moral problem is. They may also experience ethical distress when they know the
“right” thing to do, but various constraints make doing the “right” thing difficult (Jameton,
1984).
● Identifying and solving ethical problems requires sensitivity, intellectual curiosity and
commitment. If in doubt, nurses need to question and speak with colleagues. By discussing and
understanding values, and reviewing case situations, nurses can prepare themselves for ethical
practice.
Client well-being
●Promoting client well-being means facilitating the client’s health and welfare, and preventing
or removing harm. At times, it is difficult to decide what is “good” or optimal in a particular
situation. In determining the best action, it is necessary, as a beginning point, to differentiate
between the nurse’s and the client’s views of what is beneficial. Sometimes it is also difficult to
balance potential benefits with the potential harm of a given treatment choice. Nurses must use
the client’s views as a starting point.
● As in all other types of nursing, nurses who are involved in research need to respect clients’
wellbeing above all other objectives, including the search for knowledge. Research proposals,
therefore, should be prepared according to research standards and guidelines for the study of
human participants. Special attention needs to be paid to the issues of consent, overuse of clients
as participants, the riskbenefit balance, confidentiality of data and the monitoring of research. In
collecting data, nurses need to watch for adverse responses in participants, and to report positive
and negative responses promptly to the research team.
Client choice
●Client choice means self-determination and includes the right to the information necessary to
make choices and to consent to or refuse care. Clients know the context in which they live and
their own beliefs and values. As a result, when they have the necessary information, they can
decide what is best for themselves.
● Clients who are not competent in all areas of their lives may still be capable of making sound
decisions in some areas and need to be allowed an opportunity to make decisions in those areas.
When a client is incompetent, nurses need to ensure that a therapeutic relationship is maintained
within the limits possible for the client and with the substitute decision-maker. When individual
clients are incompetent to make decisions, a substitute decision-maker must always be consulted.
In Ontario, legislation and common law require that the wishes of clients or substitute decision-
makers be respected.
●Limits to choice: There are limits to client choice. For instance, clients do not have the right to
choose to endanger the safety of others. Client choice may be restricted by policies that promote
health; for example, restrictions on smoking. Client choice is also influenced by the resources
available in a particular situation.
● When values differ: Consideration of clients’ wishes may be difficult when their beliefs and
values differ from those of nurses. Nurses have their own personal values and may experience an
ethical conflict when they disagree with clients’ decisions. Nurses may believe that, as health
care professionals, they know what is best for clients; however, clients have the right to choose a
risky course of action.
Privacy and confidentiality:
●Privacy is limited access to a person, the person’s body, conversations, bodily functions or
objects immediately associated with the person. Because people have different beliefs and values
about privacy, the important aspects of privacy need to be identified by individual clients. Nurses
need to provide care that maintains the dignity and privacy of clients and should not
unnecessarily intrude on a client’s privacy
● 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. Clients, however, may consent to
sharing information with others.
Respect for life:
● Respect for life means that human life is precious and needs to be respected, protected and
treated with consideration (Keyserlingk, 1979). Respect for life also includes considerations of
the quality of life. It is sometimes difficult to identify what is human life and what society wants,
values and protects in relation to human life. It is also difficult for health care professionals,
including nurses, to be clear about their own beliefs in relation to human life, although it is
important that they be aware of their personal beliefs.
Maintaining commitments:
●Nurses have an obligation to maintain the commitments they assumed as regulated health
professionals. Maintaining commitments means keeping promises, being honest and meeting
implicit or explicit obligations toward their clients, themselves, each other, the nursing
profession, other members of the health care team and quality practice settings.
●Maintaining commitments to clients: Nurses, as self-regulated professionals, implicitly promise
to provide safe, effective and ethical care. Because of their commitment to clients, nurses try to
act in the best interest of clients according to clients’ wishes and the standards of practice.
Nurses are obliged to refrain from abandoning, abusing or neglecting clients, and to provide
empathic and knowledgeable care. The commitment to clients also includes a commitment to
respect family members and/or significant other(s), some of whose needs may conflict with those
of clients.
● Maintaining commitments to oneself: As people learn and grow, they develop their personal
values and beliefs. Nurses need to recognize and function within their value system and be true
to themselves. Nurses’ values sometimes differ from those of other health care professionals,
employers and clients, causing ethical conflict. Nurses must provide ethical care while at the
same time remaining committed to their values.
● Maintaining commitments to nursing colleagues: Nurses have a commitment to each other.
Nursing is one profession with two categories of registration: Registered Practical Nurses
(RPNs) and Registered Nurses (RNs), which includes Nurse Practitioners (NPs). Ethical nurses
are concerned about the well-being of nursing colleagues and therefore are respectful toward
each other. Respectful behaviour among nurses contributes to the best possible outcomes for
clients (Hansen, 1995).
●Maintaining commitments to the nursing profession: Nurses have a commitment to the nursing
profession. Being a member of the profession brings with it the respect and trust of the public.
To continue to deserve this respect, nurses have a duty to uphold the standards of the profession,
conduct themselves in a manner that reflects well on the profession, and to participate in and
promote the growth of the profession. (For further information, see CNO’s Professional
Standards, Revised 2002 practice standard.)
●Maintaining commitments to team members/colleagues: Much of what has been expressed in
the above paragraphs about commitment to nursing colleagues applies equally to other members
of the health care team. Nurses need to respect all health care professionals and their roles, and
are expected to collaborate and coordinate care with team members. When there are overlapping
scopes of practice between professions, the nurse needs to determine the appropriate care
provider and what is in the client’s best interest.
● Maintaining commitments to quality practice settings: Nurses are best able to provide quality
care when their environment supports quality professional nursing practice, is effective in
implementing change and responds to nurses’ concerns. All nurses, whatever their position, need
to advocate for quality practice settings. To promote quality workplaces, CNO has identified key
attributes or characteristics that support quality professional practice. These are: professional
development systems, leadership, organizational supports, response systems facilities and
equipment, communication systems and care delivery processes. Nurses should refer to these
attributes when advocating for improvements to their practice settings.
Truthfulness:
●Truthfulness means speaking or acting without intending to deceive. Truthfulness also refers to
providing enough information to ensure the client is informed. Omissions are as untruthful as
false information. As health care has changed, so have the restrictions on disclosure in dealing
with clients. Many health care professionals formerly believed that clients could be harmed by
knowing the details of their illnesses. Health care professionals now believe that clients have the
right to and will benefit from full disclosure. Honesty builds trust, which is essential to the
therapeutic relationship between nurses and clients.
Fairness:
Fairness means allocating health care resources on the basis of objective health-related factors.
The Canada Health Act provides access to health care for all Canadians. Health care resources,
however, are limited; this makes it difficult to make decisions about who receives care and what
kind of care they receive.
Assessment/description of situation:
■ Pay close attention to all aspects of the situation, taking into account clients’ beliefs, values,
wishes and ethnocultural backgrounds.
■ 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.
■ Consider policies and guidelines, professional codes of ethics and relevant legislation.
■ 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.
■ 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.)
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
consequences of refusing the treatment. 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.
CNO: Conflict Prevention and Management
● conflict refers to a power struggle in which a person intends to harass, neutralize, injure or
eliminate a rival. While conflict is an inherent part of nursing,8 the provision of professional
services to clients does not include accepting abuse.
● The Conflict Prevention and Management practice guideline replaces the 2004 Nurse Abuse
practice guideline, originally published as Abuse of Nurses in 2000. It is meant as an overview,
not as a comprehensive conflict-management resource. This guideline outlines key factors
associated with conflict with clients, colleagues and in the workplace, and offers strategies for
preventing and managing conflict that has escalated. It also highlights the role of nurses in
formal leadership positions, as well as the importance of the debriefing process in the prevention
and management of conflict.
Nurse-Client Conflict:
●The therapeutic nurse-client relationship is the foundation for providing nursing services that
contribute to the client’s health and well-being. The role of the nurse in the therapeutic nurse-
client relationship is to support the client in achieving the client’s health goals. However,
unresolved conflict can impede the attainment of these goals.
Conflict between a nurse and a client can escalate if a client is:
a) intoxicated or withdrawing from a substance-induced 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.
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.
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.
Prevention:
●One part of the therapeutic nurse-client relationship is providing client-centred care. Nurses can
provide client-centred care by following the client’s lead about information-giving and
decisionmaking, attempting to understand the meaning behind the client’s behaviour and using
proactive communication strategies that focus fully on the client. Nurses can employ client-
centred care strategies to prevent behaviours that contribute to the escalation of conflict.
Nurses can:
a) continually seek to understand the client’s health care needs and perspectives;
b) acknowledge the feelings behind the client’s behaviour;
c) ask open-ended questions to establish the underlying meaning of the client’s behaviour;
d) engage in active listening (for example, use verbal and nonverbal cues to acknowledge what
is being said);
e) use open body language to display a calm, respectful and attentive attitude;
f) acknowledge the client’s concerns about the health care system and his/her experiences as a
client;
g) respect and address the client’s wishes, concerns, values, priorities and point of view;
h) anticipate conflict in situations in which it has previously existed and create a plan of care to
prevent its escalation; and
i) reflect to understand how her/his behaviour and values may negatively affect the client.
Management:
●There are many different strategies for managing conflict that can be implemented by nurses
before conflict escalates. Conflict-management strategies should be individually tailored to each
client situation. Nurses need to use their professional judgment to determine which strategy is
most appropriate for each client.
A nurse can:
a) implement a critical incident management plan;
b) remain calm and encourage the client to express his/her concerns;
c) avoid arguing, criticizing, defending or judging;
d) focus on the client’s behaviour rather than the client personally;
e) involve the client, the client’s family and the health care team members in assisting with the
behaviour and developing solutions to prevent or manage it;
f) state that abusive language and behaviours are unacceptable, if the nurse believes this will not
escalate the client’s behaviour;
g) step away from the client, if necessary (for example, to regain composure or to set personal
space boundaries);
h) leave the situation to develop a plan of care with the assistance of a colleague if the client
intends to harm the nurse; and
i) protect themselves and other clients in abusive situations by withdrawing services, if necessary
(see the decision tree on page 11).
Conflict With Colleagues:
●Conflict among colleagues can have an indirect influence on the therapeutic nurse-client
relationship. Poor relationships among members of the health care team negatively affect the
delivery of care. For example, workplace bullying can erode a nurse’s confidence and
compromise her/his ability to foster therapeutic relationships with clients.
Conflict among colleagues can escalate if:
a) bullying or horizontal violence (Interpersonal conflict among colleagues that includes
antagonistic behaviour such as gossiping, criticism, innuendo, scapegoating, undermining,
intimidation, passive aggression, withholding information, insubordination, bullying, and verbal
and physical aggression) exists;
b) barriers to collaborative collegial behaviour encourage the marginalization of others (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;
f) new graduates and/or employees are not supported by experienced nurses 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.
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.
Management:
To function effectively as part of a team, nurses must establish positive collegial relationships.
Positive collegial relationships result from good communication, mutual acceptance and
understanding, use of persuasion rather than coercion, and a balance of reason and emotion when
working with others.24 The active management of conflict is an integral part of building positive
collegial relationships. Colleagues who work together to manage conflict effectively will help to
foster a work environment that produces positive outcomes for both nurses and clients.
Nurses can:
a) address conflict directly rather than avoiding or postponing its resolution;
b) focus on the behaviours that lead to the conflict rather than on the colleague personally;
c) validate assumptions through open dialogue with colleagues rather than acting on
misperceptions or assumptions; and
d) collaborate with colleagues to identify the underlying cause of the conflict. In some
situations, a neutral party (for example, a professional mediator) may be necessary
Workplace Conflict:
● Employers and nurses are partners in the delivery of optimal health care; they share the
responsibility for creating a healthy workplace for all members of the health care team. This
responsibility involves ensuring that conflicts do not negatively affect client health outcomes or
relationships among colleagues. A healthy workplace is an environment in which nurses can
safely identify conflict and implement systems for its management.
Conflict can escalate if:
a) organizational policies or programs aimed at identifying, preventing and managing the
incidence of conflict and abuse in the workplace do not incorporate and address prohibited
grounds under the Human Rights Code, such as race, ethnicity or sexual orientation;
b) organizational policies are not communicated to staff or adhered to at all levels;
c) there is a lack of formal performance feedback mechanisms;
d) existing formal performance feedback mechanisms do not address how behaviours affect
conflict;
e) the workplace culture promotes under-reporting of incidences of conflict;
f) managers and administrators abuse or bully;
g) managers and administrators show favouritism to certain staff members and ignore their
disruptive behaviour;
h) there is a lack of role clarity for staff;
i) communication is negatively affected by working conditions (for example, heavy workload or
fast work pace);
j) nurses and other health care professionals are working at peak stress times or under stressful
conditions;
k) working conditions are poor (for example, lack of ventilation, too much noise, safety
hazards);
l) intense organizational change exists; and/or
m) staff perceive job insecurity
Prevention:
● The aim of establishing a quality work environment is to develop a culture in which nurses
prevent conflict from escalating.31 In a quality work environment, employers provide
mechanisms that nurses can readily use to intervene in conflict before it escalates.
Employers can:
a) implement policies that do not tolerate abuse of any kind;
b) ensure that policies against workplace conflict are also directed at combating any form of
discrimination;
c) ensure that managers model professionalism in preventing and managing conflict;
d) establish and uphold organizational values, vision and mission that acknowledge the health,
safety and well-being of staff;
e) educate managers and staff in communication, as well as in conflict prevention and
management;
f) support effective collaboration and communication among health care team members,
especially between nurses and physicians (for example, interprofessional rounds);
g) implement strategies to ease the impact of change and decrease stress among staff;
h) identify and address staffing needs as soon as possible, especially at peak times; and
i) ensure a comfortable and safe physical environment (for example, use safety mirrors, security
guards, protective barriers, surveillance cameras and/or a system of alert when urgent help is
needed).
Management:
●Employers can promote quality practice settings in which nurses are encouraged to understand
conflict and employ strategies to mitigate it. Employers can institute reporting systems to help
nurses acknowledge when conflict has occurred. A fair and efficient reporting system encourages
communication among staff members by helping nurses identify underlying causes of conflict.
Open communication and understanding will promote an atmosphere of trust and respect within
the health care team.
Employers can:
a) provide a system that promotes the reporting of incidences of workplace conflict, protects
nurses from reprisal and deals with reports fairly and efficiently;
b) routinely assess the incidence of workplace conflict and implement strategies for corrective
action; and
c) institute clear policies and consequences for those who breach policies aimed at preventing
conflict and abuse.
Role of Nurses in Formal Leadership Positions:
● All nurses have the potential to demonstrate leadership in their professional roles. However,
nurses in formal leadership positions who make decisions in the workplace have particularly
important roles to play in the resolution of conflict. Nurses in formal leadership positions are
responsible for supporting nurses in effective conflict management. For example, nurse
administrators should establish systems that facilitate the development of conflict-resolution
skills for all members of the health care team.
Preventing conflict among staff members:
●All nurses lead by example. When nurses in formal leadership positions actively promote
behaviours that prevent the escalation of conflict, nurses see the value of conflict management
first-hand.
Nurses in formal leadership positions can:
a) make conflict resolution a priority among all staff members;
b) empower staff members to resolve problems among colleagues; c) provide nurses with greater
autonomy by participating in decision-making and opportunities for professional development;
d) foster positive relationships, trust and respect among staff members and promote a work
environment in which conflict-creating forms of behaviour (for example, exclusion or
dysfunctional cliques) are not tolerated;
e) recognize the factors that contribute to conflict and promptly intervene to diffuse conflict
situations before they escalate.
f) help staff members to develop conflict management interventions;
g) recognize that change can precipitate conflict and implement management strategies that
encourage positive attitudes toward change; and
h) seek learning opportunities to increase the comfort level of staff members in dealing with
conflict resolution.
Managing conflict among staff members:
●Conflict that remains unacknowledged will not disappear. Nurses in formal leadership positions
can promote conflict management among staff by establishing and using reporting processes that
are fair and confidential. By actively resolving conflict among staff, nurses in leadership
positions will help to establish equitable work environments for all members of the health care
team.
Nurses in formal leadership positions can:
a) offer a confidential environment for staff to report episodes of conflict without fear of
retribution;
b) deal with reports promptly, fairly and confidentially; and
c) ensure that appropriate follow-up procedures are in place to support nurses who have been
abused in the course of their practice.
Debriefing After a Critical Incident:
●Sometimes, despite a nurse’s best efforts to identify risk factors for conflict and implement
strategies to prevent it, conflict may escalate into a critical incident. After a critical incident has
taken place, it is important for the nurse involved to collaborate with the health care team to
debrief about the situation. Debriefing allows nurses to reflect on and learn from what has
occurred. This can provide insight into the conflict’s contributing factors, as well as contribute to
its future prevention and management.
Nurses can:
a) consult with those involved about the meaning of their experiences during the incident with
the intent to heal themselves and the client and family;
b) review and reflect on responses and recommend future strategies based on team members’
actions;
c) reflect on their own behaviour, which may have unintentionally affected the nurse-client
relationship;
d) help the client understand how his/her behaviour negatively affected the therapeutic nurse-
client relationship;
e) develop communication strategies with the client so the client can express his/her feelings
appropriately;
f) use best-practice strategies to develop a care plan for dealing with the client’s behaviour; and
g) use anticipatory planning (Involving the client in making decisions based on the client’s
values, beliefs and wishes) to develop a consistent approach of addressing the client’s behaviour
in the future.44
WEEK 4
RN and RPN Practice: The Client, the Nurse and the Environment
Practice guidelines are documents that help nurses understand their responsibilities and legal
obligations to enable them to make safe and ethical decisions when practising. They provide an
outline of professional accountabilities and relevant legislation.
– College of Nurses of Ontario
INTRODUCTION
Nursing is a profession that is focused on collaborative relationships that promote the best
possible outcomes for clients. These relationships may be
• interprofessional, involving a variety of health care professionals working together to

deliver quality care within and across settings.
• intraprofessional, with multiple members of the same profession working
collaboratively to deliver quality care within and across settings.
This document focuses on three factors—
• the client,
• the nurse and
• the environment —
to support nurses in making decisions that are specific to their intraprofessional responsibilities
when providing client care.
These three factors have an impact on decision- making related to care-provider assignment
(which nursing category (Registered Nurse [RN] or Registered Practical Nurse [RPN]) to match
with client needs), as well as the need for consultation and collaboration among care providers.
Many of the concepts in this document apply

to all nurses; however, references to nurses or intraprofessional care in this document refer only
to RNs and RPNs—Nurse Practitioners are not included in this document because the
complexity of client care does not define their involvement in care.
This document replaces the Utilization of RNs and RPNs practice guideline.
Purpose
The purpose of this document is to:
1. help nurses, employers and others make effective decisions about the utilization of
individual nurses in the provision of safe and ethical care
2. outline expectations for nurses within the three- factor framework, highlighting the
similarities and differences of foundational nursing knowledge and its impact on
autonomous practice.
3. highlight nurses’ accountabilities when collaborating with one another
4. Identify attributes of practice environments that facilitate nursing assignments, enhance
collaboration and lead to improved client outcomes and public protection.
Guiding Principles
The following principles guide nurses’ practice expectations and are the basis for decision-
making when working within the intraprofessional team.
• The goal of professional practice is to obtain the best possible outcome for clients.
• RNs and RPNs study from the same body of nursing knowledge.
• RNs study for a longer period, allowing for greater foundational knowledge in clinical
practice, decision-making, critical thinking, leadership, research utilization and
resource management.
As a result of these differences, the level of autonomous practice of RNs differs from that of
RPNs.
The complexity of a client’s condition influences the nursing knowledge required to provide the
level of care the client needs.
o A more complex client situation and less stable environment create an increased need for
consultation and/or the need for an RN to provide the full range of care requirements.
o RN=MORE COMPLEX
Respecting and understanding the expectations and contributions of the health care team
facilitates appropriate utilization of nurses, enhances collaboration and leads to improved client
outcomes.
Legal Scope Of Practice
The Regulated Health Professions Act, 1991 (RHPA) and the Nursing Act, 1991 provide the
legislative framework for nursing practice. Components of the legislative framework are a scope
of practice statement and a list of controlled acts authorized to nursing.
Controlled acts are activities that are activities potentially harmful if they are performed by
unqualified persons.
A profession’s legal scope of practice is determined by its scope of practice statement and the
controlled acts it has the authority to perform. Members of regulated health professions are
authorized to perform specific controlled acts appropriate to their profession’s scope of practice.
Having the authority to perform a procedure
does not necessarily mean that the individual is competent or that it is appropriate for the
individual to perform the procedure.
Nursing’s Scope of Practice Statement
The scope of practice statement describes in a general way what the profession does and the
methods that it uses; it refers to the profession as a whole, rather than what any individual can
do.
The scope of practice statement for nursing states:
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.
Practice is so broad and varied that no one nurse is expected to be competent to carry out all the
activities within the legal scope of practice; hence, the notion of “full scope of practice” is
unlikely.
ii. Controlled Acts Authorized to Nurses
The Nursing Act, 1991 authorizes nurses to perform the following controlled acts: performing a
prescribed procedure below the dermis or mucous membrane administering a substance by
injection or inhalation
putting an instrument, hand or finger
o beyond the external ear canal

o beyond the point in the nasal passages where they normally narrow
o beyond the larynx
o beyond the opening of the urethra
o beyond the labia majora
o beyond the anal verge, or into an artificial opening in the body
o dispensing a drug
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, behavior, communication or social functioning.
There are differences between RNs and RPNs’ authority to initiate controlled acts.
Initiation refers to independently deciding that a specific procedure within a controlled act is
required and performing that procedure in the absence of an order.
Nurses’ Accountability -Nurses show accountability by taking responsibility for their decisions
and actions, taking appropriate action when needed and ensuring that practice is consistent with
entry-to-practice competencies, standards of practice, guidelines and legislation.
Nurses are to Consult if it is beyond your competence
A nurse is not accountable for the actions and decisions of other care providers when the
nurse has no way of knowing of those actions.
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 acting 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 collaborating with
clients, with each other and with members of the interprofessional care team for the
benefit of the client.
The designated nursing authority (which is the nurse with the highest level of authority for
nursing in the practice environment) is accountable for ensuring there are mechanisms in place
such as policies, procedures, guidelines and other resources to support the following:
o utilization decisions that take into account client, nurse and environment factors,
and that are evidence-based
o nurse collaboration and consultation
o clear and well-understood role descriptions
o professional nursing practice, and
o continuity of client care.
The Three-Factor Framework
This is Making effective decisions about which nursing category (RN or RPN) to match with
client needs It involve considering three factors of equal importance:
o the client
o the nurse
o environment, and deliberating on how they apply to the situation.
Client factors
Decisions about the utilization of an RN and an RPN are influenced by:

1. complexity
2. predictability
3. Risk of negative income
Complexity- the degree to which a client’s condition and care requirements are identifiable
requirements are identifiable and established and the sum of the variables influencing a client’s
current health status, and the variability of a client’s condition or care requirements.
Predictability- the extent to which a client’s outcomes and future care requirements can be
anticipated.
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.
Client continuum
The three client factors described above combine to create a representation of the client that can
be placed on a continuum.
The continuum= less complex, more predictable and low risk for negative outcomes, to
highly complex, unpredictable and high risk for negative outcomes.
All nurses can autonomously care for clients who have been identified as less complex, more
predictable and at low risk of negative outcomes.
The more complex the care requirements, the greater the need for consultation and/or the
need for an RN to provide the full spectrum of care.
Client Factors Autonomous RN or RPN RN Involved or Providing

Practice Care
Complexity o care needs well o care needs not well

defined and defined/ established or
(Includes bio-psycho-social, established coping changing
cultural, mechanisms and o
support systems in coping mechanisms
emotional and health learning place and effective and supports
needs) health condition well unknown, not
controlled or functioning or not in
managed. place
▪ little fluctuation in o health condition not
health condition over well controlled or
time managed
▪ few factors o requires close,
influencing the frequent monitoring
client’s health and reassessment
o fluctuating health
condition many
factors influencing the
▪ client is an individual, client’s health
family, group or o client is an individual,
community family, group,
community or
population
Predictability o predictable outcomes o unpredictable

o predictable changes in outcomes
health o unpredictable changes
in health condition
Risk of negative outcomes o Unpredictable

systemic or wide-
o signs and symptoms ranging responses
are obvious o Signs and symptoms
o low risk of negative subtle and difficult to
outcomes detect
o predictable, localized o High risk of negative
and manageable outcome
responses
Nurse factors
The factors that affect a nurse’s ability to provide safe and ethical care to a given client include
leadership, decision-making and critical-thinking skills. Other factors include the application of
knowledge, knowing when and how to apply knowledge, and having the resources available to
consult as needed.
It is important for nurses to be aware of the limits of their individual competence and their
practice. Based on individual practice reflection and the current requirements of their practice
environments, nurses must continually enhance their knowledge and competence through
ongoing learning, education, experience and participation in quality assurance activities. Nurses
can become experts in an area of practice within their own nursing category; however, enhanced
competence through continuing education and experience does not mean that an RPN will
acquire the same foundational competencies as an RN. This will only occur through the formal
education and credentialing process.
Nurses consult with one another when a situation demands nursing expertise that is beyond their
competence
Consultation involves seeking advice or information from a more experience or knowledgeable

nurse or other health care professional. The amount of consultation required is determined by the
complexity of client care needs and the nurse’s competence. The practice setting influences the
availability and accessibility of these consultation resources.
An important aspect of efficient consultation

is providing nurses with the time and resources needed to consult as often as is necessary to meet
client needs.
Nurses also need to clarify their reasons for consulting and determine an appropriate course of
action.
Unless care is transferred, the nurse who sought consultation is still accountable for the
client’s care.
Consultation results in one of the following:

a) the nurse receiving advice and continuing to care for the client
b) the nurse transferring an aspect of care to the consultant
c) the nurse transferring all care to the consulta
When any care is transferred from one nurse to another, the accountability for that care is
also transferred. When a care provider assignment involves the expectation of consultation,
nurses must assess that the required consultative supports are available. When supports are
inadequate to meet client
needs and ensure quality care, nurses must take appropriate action.
Whenever the need for consultation exceeds the efficient delivery of care, it is most likely that
the client requires an RN to provide all care.
Environment factors
Environment factors include practice supports, consultation resources and the stability/
predictability of the environment. Practice supports and consultation resources support nurses in
clinical decision-making.
The less stable these factors are, the greater the need for RN staffing. The less available the
practice supports, and consultation resources are, the greater the need for more in-depth nursing
competencies and skills in the areas of clinical practice, decision- making, critical thinking,
leadership, research utilization and resource management.
Environment Factors More Stable Less Stable
Practice supports clear and identified ■ unclear or unidentified

procedures, policies, medical procedures, policies, medical
directives, protocols, plans of directives, protocols, plans of
care, care pathways and care, care pathways and
assessment tools assessment tools
■ high proportion of expert ■ low proportion of expert

nurses or low proportion of nurses or high proportion of
novice nurses novice nurses and
unregulated staff
■ high proportion of nurse’s
familiar with the environment ■ low proportion of nurse’s
familiar with the environment
Consultation resources many consultation resources few consultation resources

available to manage outcomes available to manage outcomes
Stability and predictability of ■ low rate of client turnover high rate of client turnover
the environment
■ few unpredictable events ■ many unpredictable events
Conclusion
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, reestablish priorities and determine
the need for additional resources. The technical and cognitive aspects of nursing practice cannot
be separated. Decisions about utilizing an RN or RPN are made after considering client care
requirements and the nurse’s cognitive and technical expertise in each environment.
By considering the client, nurse and environment factors, nurses and key stakeholders can
determine which category of nursing is appropriate for specific roles in client care. The
application
of the three-factor framework will help decision- makers determine which roles and activities are
not appropriate for autonomous RPN practice. Examples include, but are not limited to, the
following:
• triage nurse
• circulating nurse
• administering conscious sedation or monitoring
sedated clients (includes deep sedation and general anaesthesia).
Authorizing Mechanisms
Introduction
An authorizing mechanism—an order, initiation, directive or delegation — is a means specified

in legislation, or described in a practice standard or guideline, through which nurses obtain the
authority to perform a procedure or make the decision to perform a procedure.
The College of Nurses of Ontario (the College) is responsible for providing clear, concise and
up-to-date guidance to nurses. As self-regulating professionals, nurses are responsible for
practicing in accordance with the practice documents that the College publishes and with
relevant legislation. Understanding legislative responsibilities is critical for nurses to make
decisions about how to perform procedures safely. It is also important to ensure that nursing
practice is consistent with the College’s practice documents.
Authorizing mechanisms are complex concepts that are covered in a number of College
documents.
To create this practice guideline, the College has consolidated and condensed information in its
Decisions About Procedures and Authority practice standard and Working With Unregulated
Care Providers practice guideline.
This practice guideline provides nurses with expectations about delegation. It is intended to help
nurses provide efficient, timely access to health
care by helping them understand authorizing mechanisms, as well as their accountabilities when
using them. However, nurses should still consult Decisions About Procedures and Authority for
more information on authorizing accountabilities.
Legislation Governing Nursing Practice

The Regulated Health Professions Act, 1991 (RHPA) sets out a framework for Ontario’s
regulated health professions.3 It provides a common set of rules of procedure for the colleges
and is linked to each profession-specific act, including the Nursing Act, 1991. The RHPA
framework sets out two elements: a scope of practice statement, and a series of controlled or
authorized acts for each profession. Under these acts, nurses are given the authority to perform
controlled acts and provide client care.
There are other acts that govern the practice of health care, including nursing, in Ontario. Each
sets out requirements for practice in the settings and circumstances to which it applies. They
include (but are not limited to) the:
o Public Hospitals Act

o Healing Arts Radiation Protection Act
o Laboratory and Specimen Collection Centre
o Licensing Act
o Mental Health Act; and
o Long-Term Care Homes Act, 20074
Scope of practice and controlled acts
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.5
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.6 A regulated health professional is
authorized to perform a portion or all of the specific controlled acts that are appropriate for
her/his profession’s scope of practice. Because some scopes of practice overlap, some
professionals are authorized to perform the same, or parts of the same, controlled acts.
Controlled acts authorized to nursing
Performing controlled acts represents only a small portion of nursing practice. It is important to
note that:
▪ controlled acts are not the only procedures that can cause harm.
▪ having the authority to perform a procedure does not automatically mean it is appropriate
to do so
▪ each nurse is accountable for her/his decisions and actions.
All nurses are authorized to perform the following controlled acts:
CONTROLLED ACTS
 Performing a prescribed procedure below the dermis or a mucous membrane.

 Administering a substance by injection or inhalation.
 Putting an instrument, hand or finger

iii. beyond the larynx,
 Dispensing a drug.
 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.
A Registered Nurse (RN) or Registered Practical Nurse (RPN) is authorized to perform these
controlled acts under the following two conditions:
if initiated in accordance with the conditions
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.
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.
6. Administering a substance by injection or inhalation, in accordance with the regulation, or

procedure.
7. Prescribing, dispensing, selling and compounding a drug in accordance with the regulation.

Authorizing Mechanisms
Authorizing mechanisms provide nurses with the authority to implement treatment plans and
protocols. Choosing the appropriate authorizing mechanism depends on the nurse’s category or
class, role and practice setting.
Orders
An order is a prescription for a procedure, treatment, drug or intervention.8 An order is required

when:
▪ a procedure falls within one of the controlled acts authorized to nursing, when a nurse has
not initiated the act.
▪ a procedure does not fall within any controlled act, but is part of a medical plan of care.
▪ a procedure falls within one of the controlled acts are authorized to nursing; or
▪ a procedure/treatment/intervention is not included in the RHPA but is included in another
piece of legislation.10
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.
Directives
A directive is an order for a procedure or series of procedures that may be implemented for
several 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.
Initiation
Under the Act, RNs or RPNs who meet certain conditions have the authority to initiate specific
controlled acts. This means that RNs or RPNs can decide independently that a specific procedure
is required, and they may initiate that procedure in
the absence of a specific order or directive from an authorizing professional. When initiating a
controlled act, an RN or RPN must:
 assess the client and identify the problem.

 consider all the available options to address the problem.
 weigh the risks and benefits of each option considering the client’s condition.
 decide on a course of action.
 anticipate the management of potential outcomes
 And accept accountability for deciding that the procedure is required and for ensuring
that any potential outcomes are managed appropriately.
RNs or RPNs who consider initiating procedures are advised to clarify with their colleagues and
employers the scope of their roles and responsibilities within the health care team. If initiating is
within the scope of the RN or RPN’s role and competence, and is not prohibited by legislation or
organizational policy, the initiating RN or RPN may perform the procedure, or an RN may write
the order for the procedure and another nurse may perform it.
Conditions for initiating controlled acts
Competence: The person who is initiating must have the knowledge, skill and judgment to
perform the procedure safely, effectively and ethically
determine whether the client’s condition warrants the performance of the procedure.
Client factors: The person who is initiating must:

 have a nurse-client relationship with the client
 determine that the client’s condition warrants the performance of the procedure having
considered:
 the known risks and benefits to the individual
 the predictability of the outcomes of performing the procedure, and

 other relevant factors specific to the situation.
Environmental support: The person who is initiating must have the appropriate resources to
perform the controlled act safely and manage reasonably expected outcomes.
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.
Restrictions on initiating controlled acts
Although RNs and RPNs have the legal authority to initiate a controlled act, in practice the
opportunity to initiate may be limited by other legislation or practice-setting policies. A specific
facility may not permit its nursing staff to initiate controlled acts. For example, RNs and RPNs
cannot initiate treatments in a hospital setting because the Public Hospitals Act grants only
physicians, NPs, midwives and dentists the authority to order treatments.
Who can delegate, which acts can be delegated and who can accept delegation
Nurses can delegate and accept delegation if they are registered in the General, Extended? or
Emergency Assignment Classes. 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 be able to accept delegation.
A nurse may need additional preparation to delegate or accept delegation competently,

depending on her/ his nursing experience and the type of procedure being delegated.
All of the controlled acts authorized to nursing can be delegated with the exceptions described
below.
Restrictions on delegating
RNs and RPNs cannot delegate the controlled

act of dispensing a drug and 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, behavior, communication or social
functioning.
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.
Sub-Delegation
Nurses can only delegate those acts which they have the authority to perform. They cannot
delegate an act that has been delegated to them. This is referred to as sub-delegation.
Nurses can only accept delegation from regulated health professionals who are authorized to
perform those controlled acts by a health profession act governing their profession. They cannot
accept delegation from anyone who is not authorized to perform controlled acts through a health
Delegation and orders
Delegation and orders are two distinct authorizing mechanisms. However, not all health
profession acts make this distinction. To address any confusion between orders and delegation,
nurses must understand that delegation may or may not include an order, and an order may or
may not indicate a delegation. Delegation provides the legal authority to perform a controlled
act, whereas an order outlines how to perform it.
For example, an RN or RPN may obtain the authority to adjust a cardiac pacemaker through
delegation. When the process includes parameters for adjusting the pacemaker and the
expectations for delegation have been met, this is considered an order within delegation.
However, if the delegation document does not include this information, then it is not an order.
The RN or RPN would then require a direct order to perform the adjustment.
Delegation by nurses
Nurses delegate-controlled acts within most practice environments, most commonly to UCPs
(unregulated care providers), such as family members of clients. They also delegate certain
controlled acts to other regulated health professionals who do not have legal authority to perform
a controlled act that is authorized to nursing.
A nurse who delegates a controlled act is responsible for the decision to delegate the controlled
act. For example, a nurse is responsible for the decision to delegate the care of a wound to a UCP
or family member; and she or he must meet all the requirements for delegating before the
authority
for that care is transferred. Delegation can be oral or written, and appropriate documentation of
the particulars of the delegation must be maintained.
The RHPA includes an exception allowing UCPs to perform some controlled acts if they are
routine activities of living. Procedures are routine activities of living when the need for, response
to, and outcome
of the procedure have been established over time and are predictable. For instance, administering
the same dosage of insulin to a person with well-controlled diabetes over an extended period is a
routine activity of living. It is not a routine activity if the dosage or type of insulin requires
frequent adjustment
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 delegate 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 delegate 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 aids or treatment for the client.
Requirement 8
When the delegateeis 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.
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.
Accepting delegation
Nurses who perform controlled acts that are delegated to them are responsible for the decision to
carry out the controlled act and for the performance of the act.
Requirements for Accepting Delegation
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.
Documenting the particulars of delegation
Any record of the particulars of a delegation must include:

(a) the date of the delegation
(b) the delegator’s name, if the controlled act was delegated to the nurse
(c) the delegatee’s name, if the controlled act was
delegated by the nurse, and

(d) the conditions, if any, applicable to the delegation.
Tools for Delegating, Accepting Delegation and Developing Directives

The Federation of Health Regulatory Colleges
of Ontario has developed resources to facilitate collaboration among health care providers when
using authorizing mechanisms. An Interprofessional Guide on the Use of Orders, Directives and
Delegation for Regulated Heath Professionals in Ontario17 includes statements, principles and
definitions regarding the use of authorizing mechanisms, and a tool kit for developing
authorizing mechanisms. These resources are congruent with the College’s expectations.
Assigning, Supervising or Teaching a Procedure

A nurse who assigns, supervises or teaches a procedure has a unique role on the health care team.
Because these activities do not require the formal transfer of authority, they may be perceived as
being less important. However, in all roles the nurse is accountable for determining that the
person who is being assigned, supervised or taught to provide care is competent to provide that
care and manage outcomes. The nurse’s priority is to ensure that the client receives safe and
ethical care.
Assigning a procedure
Assigning is determining or allocating responsibility for particular aspects of care that may
include controlled and non-controlled act procedures. Assigning care may require nurses to
supervise aspects of care or teach procedures.
Depending on the responsibilities of their positions, RNs, RPNs and NPs with the necessary
knowledge, skill and judgment may assign care to other nurses or UCPs. Ideally, a range of care
needs, rather than specific isolated procedures, is assigned. For example, assigning the complete
care of certain clients on a unit to one nurse is likely preferable to assigning all dressing changes
for all clients on the unit to one nurse.
Supervising a procedure
Supervising is monitoring and directing specific activities of others for a defined period.
Supervising does not include ongoing managerial responsibilities.
Depending on the responsibilities of their positions, RNs, RPNs and NPs may supervise others.
This role includes providing the appropriate degree
of either direct or indirect supervision to the individual being supervised. It is based on the
client’s condition, the nature of the procedure(s), the resources available in the setting and the
degree of competence of the person being supervised.
Teaching a procedure
Teaching is providing instruction, determining that a person is competent to perform a procedure

and evaluating the learning. Teaching is not equivalent to delegation because it does not involve
the transfer of authority to perform a controlled act.
Decision Tree #1: Deciding to Perform a Procedure

Appendix A: Procedures RNs and RPNs May Initiate According to the
12 Nursing Act, 1991
An RPN may initiate but cannot provide An RN may initiate and/or provide an
an order for another nurse to perform order for an RN or RPN to perform
Care of a wound below the dermis or below a  Care of a wound below the dermis or
mucous membrane: below a mucous membrane:
 cleansing
 cleansing  soaking
 soaking  irrigating
 dressing  probing
 debriding
 packing
 dressing
Venipuncture to:
▪ establish peripheral venous access and

maintain patency when client requires
medical attention and delaying
venipuncture is likely to be harmful
◗ 0.9% NaCl only
For the purpose of assisting client with For the purpose of assisting client with health
health management activities that require management activities that require putting an
putting an instrument beyond the: instrument beyond the:
■ point in the nasal passages where they
▪ point in the nasal passages where they normally narrow
normally narrow ■ larynx
▪ larynx ■ opening of the urethra
▪ opening of the urethra
For the purpose of: For the purpose of:

■ assessing client
■ assisting client with health ■ assisting client with health management
management activities Procedure that activities Procedure that requires putting an
requires putting a hand or finger instrument, hand or finger beyond the:
beyond the: ■ labia majora
■ labia majora
For the purpose of: For the purpose of:

■ assessing client
▪ assessing client ■ assisting client with health management
▪ assisting client with health activities Procedure that requires putting an
management activities Procedure that instrument or finger beyond:
requires putting an instrument or ■ the anal verge
finger beyond the: ■ an artificial opening into client’s body
▪ anal verge
Treating, by means of psychotherapy Treating, by means of psychotherapy

technique, delivered through a therapeutic technique, delivered through a therapeutic
relationship, relationship,
an individual’s serious disorder of thought, an individual’s serious disorder of thought,
cognition, mood, emotional regulation, cognition, mood, emotional regulation,
perception or memory that may seriously perception or memory that may seriously
impair the individual’s judgement, insight, impair the individual’s judgement, insight,
behavior, communication or social behavior, communication or social
functioning. functioning.
RNs and RPNs cannot initiate procedures that involve putting an instrument or finger into one of
the body openings or into an artificial opening of the body for the purpose of treating a health
problem. Authorized procedures are also limited to those procedures that do not require the use
of a prescribed drug, as nurses in the General Class are not authorized to prescribe drugs.
Decision Tree #2: Assigning, Supervising or Teaching a Procedure
Working With Unregulated Care Providers
Practice guidelines are documents that help nurses understand their responsibilities and legal
obligations to enable them to make safe and ethical decisions when practising. They provide an
outline of professional accountabilities and relevant legislation.
— College of Nurses of Ontario
Introduction
Increasingly, unregulated care providers (UCPs) assist with, or perform, certain aspects of care
traditionally provided by regulated health care professionals. Nurses1 are often expected to
teach, supervise or assign health care to others.
A nurse cannot assume that a UCP2 is competent to perform any procedure, regardless of how
straightforward the procedure appears.
Although a UCP may have the authority to perform a procedure through an exception,3
delegation
or because the procedure is not a controlled act, that does not mean that the UCP is competent to
perform the procedure or that it is appropriate for the UCP to perform it. The nurse must
determine appropriateness in each client4 situation, and then ensure that measures are in place to
promote the UCP’s continuing competence.
This practice document clarifies the roles and responsibilities of nurses in relation to UCPs and
identifies expectations for nurses when UCPs
are part of the health care team. T
Expectations for nurses who work with UCPs

A nurse who teaches, assigns duties to or supervises UCPs must:
know the UCP is competent to perform the particular procedure or activity safely for the client
in the given circumstances. When teaching a UCP, a nurse is expected to have first-hand
knowledge of the UCP’s competence. A nurse who assigns or supervises is expected to verify
that the UCP’s competence has been determined.
ensure that the UCP: understands the extent of her or his responsibilities in performing the
procedure(s) knows when and who to ask for assistance, and knows when, how and to whom to
report the outcome of the procedure.
ensure that there is an ongoing assessment of the client’s health care needs, develop a plan of
care, evaluate the client’s condition and judge the ongoing effectiveness of the UCP’s
interventions.
UCPs perform a variety of tasks based on their employment setting and on the role or
employment description the employer provides.
Nurses who delegate to UCPs must do so in accordance with regulation. When the employer
and/or nurse are determining appropriate tasks for a UCP, they should assess:
▪ each client’s situation and condition

▪ the activity and associated risk, and
▪ the environmental supports.
UCPs are accountable to their employers. They are not accountable to an external body, and
there is no regulatory mechanism to set standards or monitor quality of service.
For more information, review Appendix A (Decision Tree: Making Decisions About Activities
Performed by UCPs) on page 8.
Controlled acts and exceptions
Controlled acts are activities that are considered to be potentially harmful if performed by
unqualified individuals. This document addresses three of the controlled acts authorized to
nursing under the Nursing Act, 1991.6 They are:
1. Performing a prescribed procedure below the dermis or mucous membrane

2. Administering a substance by injection or inhalation, and
Putting an instrument, hand or finger:

beyond the larynx beyond the opening of the urethra beyond the labia majora
vii. into an artificial opening in the body.
A UCP only has the authority to perform a controlled act through an exception or when
an individual who has the authority to order or perform the act delegates7 this authority to the
UCP. The Regulated Health Professions Act, 1991 identifies a number of exceptions that allow
individuals who are not members of a regulated health profession to perform some controlled act
procedures. These exceptions include:
1. treating a member of her/his household, and the procedure falls within the second or third
controlled acts authorized to nursing, and
2. assisting a person with routine activities of living, and the procedure falls within the second or
third controlled acts authorized to nursing (see the table below).
A procedure is considered to be a routine activity of living when its need, response and outcome
have been established over time and are predictable.
Authority to perform procedures
Procedure
▪ Performing procedure below the dermis or mucous membrane

▪ Administering a substance by injection or inhalation
▪ Putting an instrument, hand or finger into a body orifice or artificial opening into the
body
▪ Procedures not included in the controlled acts
Member of household (family member)
▪ Not included in exception; requires delegation

▪ Exception permits performance in any circumstance
▪ Exception permits performance in any circumstance
▪ No authority required to perform
Other (paid care provider)
▪ Not included in exception; requires delegation

▪ Exception permits performance if part of routine activity of living
▪ Exception permits performance if part of routine activity of living; otherwise requires
delegation
▪ No authority required to perform
Teaching, Delegating, Assigning and Supervising
Teaching
Teaching involves providing instruction and determining that a UCP is competent to perform a
procedure.
A nurse may teach a controlled act procedure to a UCP when the nurse meets all of the following
six requirements:
Requirement 1
The nurse has the knowledge, skill and judgment to perform the procedure competently.
Requirement 2
The nurse has the additional knowledge, skill and judgment to teach the procedure.
Requirement 3
The nurse accepts sole accountability for the decision to teach the procedure after considering:
▪ the known risks and benefits to the client of performing the procedure
▪ the predictability of the outcomes of performing the procedure
▪ the safeguards and resources available in the situation, and
▪ other factors specific to the client or setting.
Requirement 4
The nurse has determined that the UCP has acquired, through teaching and supervision of
practice, the knowledge, skill and judgment to perform the procedure.
Requirement 5
The nurse may teach the procedure to a UCP to perform for more than one client if she or he has
determined that the factors in Requirements 3 and 4 are conducive to performing the procedure
for more than one client.
Requirement 6
Procedure Member of household (family Other (paid care provider)

member)
Performing procedure below the dermis or Requires delegation Requires delegation

mucous membrane
Administering a substance by injection or Does not require delegation Requires delegation if not a
inhalation routine activity of living
Putting an instrument, hand or finger into a Does not require delegation Requires delegation if not a
body orifice or artificial opening into the routine activity of living
body
Procedures not included in the controlled Does not require delegation Does not require delegation
acts
Considering the factors in Requirements 3 and 4, the nurse evaluates the continuing competence
of the UCP to perform the procedure or reasonably believes that a mechanism is in place to
determine the UCP’s continuing competence.
If the nurse is also delegating the controlled act to the UCP, see the section on delegation in this
document and the Authorizing Mechanisms practice guideline for additional requirements that
the nurse must meet.
Delegation is the transfer of authority to perform a controlled act procedure from a person who is
authorized to perform the procedure to a person who is not otherwise authorized to perform the
procedure. Nurses who delegate to UCPs must ensure that they follow the requirements for
delegation, which are described in Authorizing Mechanisms.
When is delegation required?
Assigning
Assigning is the act of determining or allocating responsibility for particular aspects of care to
another individual. This includes assigning procedures that may or may not be a controlled act.
Ideally, a range of care needs, rather than specific procedures, are assigned. Depending on the
nature and responsibilities of their positions, nurses with the necessary knowledge and judgment
may assign care to a UCP. In some instances, the delegator or the teacher may also assign care to
a UCP.
Supervising
Supervising involves the monitoring and directing of specific activities of UCPs. It does not
include ongoing managerial responsibilities. Often, the person who assigns a task also supervises
the performance of that task. Supervision can be direct or indirect, depending on the
circumstances. For direct supervision, the supervisor is physically present during the provision of
care. For indirect supervision, the supervisor is not physically present but monitors activities by
having the UCP report regularly to the supervisor, or by periodically observing the UCP’s
activities.
Teaching Delegating Assigning Supervising

What is it? Deciding to Transferring the Allocating Monitoring
teach, providing authority to responsibility for and directing
instruction and perform a providing care performance of
determining controlled act specific
competence to procedure to activities for
perform a a person not defined time
procedure authorized to period; may be
perform that act direct or indirect
What does it Any procedure Controlled act Any procedure Any procedure
apply to? procedures only
Who may do it? A nurse who A nurse who A nurse with the A nurse with the
meets the six meets the necessary necessary
requirements requirements knowledge and knowledge and
discussed on in Authorizing judgment judgment
page 5 Mechanisms
Conclusion
This document explores the essential factors that must be considered when working with UCPs.
Nurses who work with UCPs have certain accountabilities related to teaching, delegating,
assigning and supervising, depending on the nature of their role.
When the employer and/or nurse is determining what tasks are appropriate for a UCP, she or he
should assess each client’s situation and condition,
the activity and its associated risks, and the environmental supports that are available. A
thorough decision-making process is a critical component in promoting client safety when UCPs
are involved in client care.
Decisions About Procedures and Authority
Nursing standards are expectations that contribute to public protection. They inform nurses of
their accountabilities and the public of what to expect of nurses. Standards apply to all nurses
regardless of their role, job description or area of practice.
— College of Nurses of Ontario
Introduction
As knowledge and technology advance and health care environments change, nursing practice
evolves. Increasingly, nurses1 face decisions about performing procedures that are new, or were
previously the responsibility of other professionals. This practice document outlines the
expectations of nurses when determining if:
▪ They have the authority to perform a procedure,

▪ It is appropriate for them to perform a particular procedure; and
▪ They are competent to perform the procedure.
▪ This document allows for flexibility in nursing roles while protecting the public interest. It
facilitates timely, efficient access to health care and fosters effective interprofessional
collaboration, while ensuring that appropriate measures are in place to promote safe,
effective and ethical client care. nurses may consider accepting delegation4,5 of any
controlled act procedure not authorized to nursing if they comply with requirements in
regulation.
▪ Nurses must adhere to this practice standard when performing any procedure related to nursing
practice. This includes procedures authorized to nurses in the nursing act, 1991, those
delegated, those carried out in emergencies and those that do not fall within a controlled
act.
publishes practice standards to:
▪ outline the generally accepted expectations of nurses and set out the professional basis of
nursing practice.
▪ provide a guide to the knowledge, skill, judgment and attitudes that are required to
practice safely.
▪ describe what each nurse is accountable for in practice; and
▪ achieve public protection when adhered to.
College practice documents apply to all nurses regardless of their roles or areas of practice.
This practice document helps nurses, nursing administrators and employers to make appropriate
decisions about nurses performing procedures, including procedures that require additional
authority (e.g., delegation). If standards are breached, it could be professional misconduct.
Making decisions about procedures and authority is a complex issue that can have serious
ramifications. This document has organized the factors that a nurse has to consider when making
a decision about performing a procedure.
There are four standard statements with indicators that describe a nurse’s accountabilities when
performing any procedure. Use the Decision Tree on page 10 and the Decisions About
Performing Procedures chart on page 11 to work through a procedure relevant to your individual
practice.
Appendix A contains an overview of the relevant legislation concerning authorization and the
performance of procedures, the Regulated Health Professions Act, 1991 (RHPA) and the Nursing
Act, 1991. These acts acknowledge the overlapping scopes of practice among regulated health
professionals. They also provide a flexible framework for changes in practice to accommodate
advances in technology and health care.
Glossary
This section defines terminology that is used throughout this practice standard. Many of these
words have specific meanings in legislation, and their meanings can differ from the general
understanding of the words in everyday use.
Authorizing mechanism. An authorizing mechanism is a means by which the authority to

perform a procedure is obtained or the decision is made to perform a procedure. The appropriate
authorizing mechanism depends on the nurse’s category or class, role and practice setting.
Examples of authorizing mechanisms include orders, initiation, directives and delegation.
Delegation and orders are distinct authorizing mechanisms, but a delegation may include an
order. For example, an RN or RPN obtains the authority to adjust cardiac pacemakers through a
formal delegation process. The RN or RPN also needs to know the parameters to adjust the
cardiac pacemaker for a particular client. The delegation could include criteria describing when
it is appropriate to perform the controlled act. (This would replace the need for client-specific
orders.) Alternatively, an order for a particular client could provide this information. See the
Authorizing Mechanisms practice document for more information.
Delegation. Delegation is a formal process that transfers the authority to perform a controlled
act. A regulated health professional who has the legislated authority and competence to perform
a procedure within one of the controlled acts can delegate that procedure to others. See the
Authorizing Mechanisms practice document for the requirements for nurses who delegate or
accept delegation.
Direct client order. A client-specific order can be an order for a procedure, treatment, drug or
intervention for an individual client. An individual practitioner (e.g., physician, midwife, dentist,
chiropodist or NP) directs a specific intervention to be performed at a specific time(s) for a
specific
client. A direct order may be written or oral; for example, given by telephone. Preprinted orders
are supportive tools that require a client’s name, the date and an authorizing signature before
implementation.
Directive. A directive is an order for a procedure, treatment, drug or intervention that may be
implemented for a number of clients when specific conditions are met and specific circumstances
exist. Most often a directive is a physician’s order, and it is always written. For more
information, refer to the College’s practice guideline Directives.
Initiation. Regulations under the Nursing Act give RNs and RPNs who meet certain conditions
the authority to initiate specific controlled acts. These nurses may independently decide that a
specified procedure is required and initiate that procedure in the absence of a direct order or
directive. The conditions are outlined in Appendix D.
While RNs and RPNs have the authority to initiate, the opportunity may be limited in practice by
legislation, role or practice-setting policy. For example, the Public Hospitals Act, regulation 965
requires an order from an identified practitioner, such as an NP or a physician, for patient
treatments and diagnostic procedures.
Order. An order is a prescription for a procedure, treatment, drug or intervention. The RHPA,
Nursing Act and other legislation, such as the Public Hospitals Act, identify the health care
providers who can provide orders for client care. The order is the decision to perform the
procedure for a particular client or group of clients. Orders are required when: ■ a procedure
falls within one of the controlled
acts authorized to nursing when the nurse does not have the authority to independently decide to
perform (i.e., initiate) the procedure.
■ required under the Public Hospitals Act, Healing Arts Radiation Protection Act or other
legislation governing client services; and
■ required by a practice-setting policy or as agreed on within the physician’s plan of care.
Professional misconduct. The Nursing Act includes regulations that identify professional
misconduct. Some of the professional misconduct regulations relevant to a nurse’s decision to
accept delegation and perform procedures include the following.
▪ Contravening a standard of practice of the profession or failing to meet the standard of practice
of the profession.
▪ Directing a member, student or other health care team member to perform nursing functions
for which she or he is not adequately trained or competent to perform.
▪ Failing to inform the member’s employer of her or his inability to accept specific
responsibility in areas in which specific training is required or for which the member is
not competent to function without supervision.
▪ Contravening a provision of the Nursing Act, the Regulated Health Professions Act, 1991 or
regulations under either of those acts.
Standard Statements
There are four standards, each with accompanying indicators, that describe a nurse’s
accountabilities when performing any procedure, whether or not it requires delegation.
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.
indicators
The nurse meets the standard by:

▪ having sufficient knowledge, skill and judgment to determine the appropriateness of
performing the procedure at a given time for a particular client, considering the:
▪ client’s overall condition,
▪ risks and benefits (e.g., predictability and severity of possible outcomes, risk of harm arising
from performing or not performing the procedure),
▪ available resources to support the performance of the procedure (e.g., emergency equipment,
cardiac arrest team) and manage outcomes.
▪ advocating for the appropriate health care provider to perform the procedure.
▪ ensuring that the rationale for performing the procedure is based on achieving the best
outcomes for the client;
▪ determining whether the procedure fits within a professional nursing role (e.g., requires
nursing assessment, health teaching, counselling, discharge planning);
▪ ensuring that practice setting policies support the nurse in performing the procedure;
▪ performing procedures at the point of client care in practice settings where health services are
routinely performed;
▪ declining to perform the procedure when it does not support safe and ethical client care; and
▪ ensuring that informed consent includes the information that a nurse is performing the
procedure.
In addition, the nurse in an administrative role meets the standard by:
■ using knowledge, best evidence, skill and judgment to determine whether a nurse is the
appropriate practitioner to perform the procedure after considering the:
◗ specialized knowledge required and whether nurses can develop the necessary knowledge,
skill and judgment to perform the procedure safely,
◗ qualifications required (e.g., the category6 and class of nursing registration [NP, RN or
RPN]),
education and related experience, ◗ overall care needs of the client population, ◗ risks and
benefits (e.g., predictability of outcomes, risk of harm arising from performing or not performing
the procedure), and
◗ whether the rationale for a nurse to perform the procedure supports timely access to care,
continuity of care and client care that focuses on the whole person;
■ ensuring that sufficient nursing resources are available to incorporate the procedure into the
practice (e.g., if nurses take on the procedure, considering how workload is affected and planning
to offset additional responsibilities);
■ mobilizing sufficient resources to support the safe performance of the procedure.
■ providing educational resources to support nurses learning to perform the procedure safely;
and
■ evaluating client outcomes in relation to nurses performing the procedure.
2. Authority
Nurses ensure that they have the appropriate authority before performing procedures.
Indicators
▪ knowing the scope of practice of nursing, the legislated authority and what the practice setting
has approved as a nurse’s role and responsibilities;
▪ knowing when additional authority is required in the form of delegation7, and proceeding with
delegation according to regulation;
▪ knowing when specific direction for client care is required in the form of orders, directives,
protocols or recommendations;
▪ obtaining direct client orders or implementing directives appropriately.
▪ ensuring that client records reflect the procedures that were performed;
▪ initiating the performance of controlled act procedures within the boundaries of legislation,
competence and agency policy; and
▪ ensuring that client records reflect the initiated procedures.
In addition, the nurse in an administrative role meets the standard by ensuring that:
■ a functional conflict-resolution mechanism exists for nurses to resolve issues/disagreements

regarding performing procedures
■ quality assurance mechanisms monitor the impact of the authorizing mechanism on client
care and ensure that required changes are made in a timely manner, and
■ documentation of authorizing mechanisms are maintained.

3. Competence
Nurses ensure that they are competent in both the cognitive and technical aspects of a
procedure prior to performing it.
Indicators
▪ demonstrating cognitive and technical competence to perform the procedures;

▪ declining to perform procedures that she/he is not competent to perform;
▪ determining the appropriateness of the procedure for the specific client in a specific situation;
▪ demonstrating knowledge of the following components of procedures:
o purpose (assessment or treatment),
o indications,
o contraindications,
o risk to the client,
o expected outcomes,
o actions to take if complications occur, and
o health teaching and decision support;
■ applying knowledge, best evidence, skill, judgment and appropriate authority to make and act
on decisions required during the procedure;
■ consulting when she/he reaches the limits of her/ his knowledge, skill and judgment.
■ communicating with other health care team members as necessary for safe, effective and
ethical client care; and
■ reflecting on and continuously improving knowledge, skill and judgment in relation to

practice.
In addition, the nurse in an administrative role meets the standard by: ■ ensuring that
resources support the delivery of
initial and ongoing education to support nurses in attaining and maintaining competence.
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.
Indicators
▪ identifying the potential risks and outcomes related to performing a procedure.

▪ determining whether the management of the possible outcomes is within her/his knowledge,
skill, judgment and authority.
▪ identifying the required resources (present and future) to manage outcomes before performing
a procedure.
▪ managing outcomes independently within her/his abilities and authority.
▪ advocating for and accessing required resources; and
▪ declining to perform procedures when she/he cannot manage the outcomes or does not have
the required resources available to manage the outcomes9 and communicating that
decision appropriately.
In addition, the nurse in an administrative role meets the standard by:
■ ensuring that the required resources are available to always manage outcomes when the
procedure is performed; and
■ supporting a nurse when she/he declines to perform procedures for which she/he does not have
the knowledge or skill to manage the outcomes and/or does not have the required available
resources.
How To Apply This Standard
Using the knowledge gained from reading this document, work through a procedure relevant
to your individual practice with the help of the following two charts.
Decisions about performing procedures

Practice setting planning considerations Individual nurse considerations
■ What are the care requirements of the client ■ Is this procedure appropriate for this
population? client at this time in this situation?
■ What are the associated benefits and risks? ■ What are the associated benefits and
Client ■ Will nursing involvement support safe, risks?
effective and ethical client care?
■ What competencies are required to perform

the procedure safely, effectively and
ethically?
■ Can nurses develop the necessary Do I have the necessary knowledge, skill
knowledge, skill and judgment to perform the and judgment to:
procedure safely? a. assesses the appropriateness of
performing?
■ Which nursing category and what level of
experience and education are necessary? the procedure?
b. perform the procedure?
c. manage the client during and after the
■ Will there be support for continuing
Nurse
education programs for nurses to attain and procedure?
maintain competence? ■ How will I attain/maintain my
competence?
■ If the procedure is added, what impact
will it have on the nurses’ ability to provide ■ Do I have the authority to perform the
nursing services (health teaching, emotional
support)?
procedure?
■ How will this impact be addressed? ■ Do I have the authority to manage the
client's
care while performing the procedure?
Environment ■ Is the procedure within the documented role ■ Is the performance of the procedure
description of the provider identified to supported in my practice setting’s role
perform the procedure? expectations?
■ What authorizing mechanisms are needed ■ Are the necessary resources available
to perform the procedure? to support me in providing safe, effective
■ What value does nursing add to the and ethical client care during and after
performance of the procedure? performing the procedure?
■ Are the necessary human and material ■ Will these resources continue to be
resources available and accessible now and in available whenever the procedure is
the future to support safe, effective and performed?
ethical client care?
Maintaining a Quality Practice Setting
As partners, both employers and nurses share responsibility for creating environments that
support quality practice. The following strategies can help you develop and maintain a quality
practice setting that supports nurses in providing safe, effective and ethical care.
Care delivery processes
Care delivery processes support the delivery of and access to nursing care and services, including
the appropriate use of delegation and other authorizing mechanisms. Possible strategies include:
▪ quality assurance processes that acknowledge positive outcomes and address negative
outcomes or critical incidents; and
▪ client care processes and policies that support nurses in meeting this practice standard.
Leadership
Leadership is the process of supporting others to improve client care and services by promoting
professional practice. Possible strategies include:
▪ assessing procedures appropriate for nurses to perform, including those delegated to nurses.
▪ supporting nurses in situations in which they decline to perform a procedure on the basis that
it is not safe for the client; and
▪ proactively identifying situations in which delegation or directives may be required and
planning to develop the necessary tools.
Organizational supports
Organizational supports include the policies, procedures, norms and values of the organization.
Possible strategies include:
▪ promoting consistency in delegation processes, including documentation and educational
requirements.
▪ establishing a clear reporting structure for a nurse who needs to decline performing a
procedure; and
▪ ensuring that the defined nursing role enables flexibility to meet the changing practice
realities while maintaining the integrity of nursing.
Communication systems
Communication systems support information- sharing and decision-making about the

performance of procedures in the context of care delivery. Possible strategies include:
■ encouraging communication systems that promote the sharing of information among all of the
interdisciplinary team members; and
■ establishing policies to assist nurses in effectively managing conflict when declining to

perform procedures that they are not competent to perform.
Facilities and equipment
The physical environment and access to equipment supports nurses in the performance of
procedures. It is important to ensure the availability of appropriate equipment and other
resources to support the safe performance of procedures. Possible strategies include:
■ ensuring that resources (both physical and human) are available and will be available in the
future; and
■ assessing if required resources, such as physician consultation, are available during the entire
course of treatment.
Professional development systems
Nurses need professional development systems to attain and maintain competence. Professional
development systems need to include orientation programs, educational opportunities, positive
learning environments and professional practice procedures. Possible strategies include:
▪ offering educational opportunities to meet the needs of nurses expected to perform new
procedures and to support nurses in maintaining competence; and
▪ providing an orientation to the process and the requirements of delegation, including the
specific documentation requirements of delegation processes.
NURSE PRACTITIONAL PRACTICE STANDARD

The College of Nurses of Ontario presents: the Nurse Practitioner practice standard webcast. This
webcast is designed to help Nurse Practitioners, or NPs, also known as Registered Nurses in the
Extended Class, apply the accountabilities in the Nurse Practitioner practice standard, and to help others
understand NP practice. This webcast is divided into six sections. Each will take approximately five
minutes to complete.
SECTION 1: Introduction and scope of practice

WHO ARE NURSE PRACTITIONERS?
• Registered nurses in the extended class
• NPs can
• Make diagnoses
• Order tests
• Prescribe medications and treatments
Nurse Practitioners are Registered Nurses in the Extended Class. They have met the additional nursing
education, clinical experience and exam requirements that build and expand on the entry‐to‐practice
competencies of the Registered Nurse. NPs are authorized to diagnose, order, and interpret diagnostic
and laboratory tests, and prescribe medication and other treatments for patients. NPs practise with
diverse patient populations and in a variety of practice settings and locations. All NPs have one or more
specialty certificates. This will be covered in the next chapter. The goal of NP practice is the same as all
nursing practice: to optimize the health and wellness of clients.
SCOPE OF PRACTICE
• Regulated Health Profession Act, 1991
• Nursing Act, 1991
• Scope of practice statement
• Controlled acts authorized to NPs
The Regulated Health Professions Act, 1991, and the Nursing Act, 1991, set the legal framework for
nursing practice in Ontario. The nursing scope of practice statement, which applies to all nurses, states
that: “The practice of nursing is the promotion of health, and the assessment, provision of care, and
treatment of health conditions by supportive, preventative, therapeutic, palliative and rehabilitative
means to attain or maintain optimal function.” The Nursing Act also identifies the controlled acts that
NPs are authorized to perform.
ADDITIONAL CONTROLLED ACTS

• Communicating a diagnosis
• Prescribing, dispensing, selling, and compounding a medication
• Setting or casting a bone fracture or joint dislocation
• Applying and ordering the application of a prescribed form of energy
In addition to the controlled acts that all nurses can perform, NPs can perform the following controlled
acts: ‐communicating to a client, or a client’s representative, a diagnosis made by the NP ‐prescribing,
dispensing, selling, and compounding medication ‐setting or casting a bone fracture or joint dislocation,
and ‐applying and ordering the application of a form of energy. NPs can perform any of these controlled
acts without an order (or prescription) from a physician. Some of these controlled acts have conditions
or restrictions on them. Legislation may allow NPs to perform these activities, or to order other nurses
to perform these activities, depending on their practice setting. For example, the Public Hospitals Act
allows NPs who are employees or who have hospital privileges, to admit, discharge and treat hospital
patients. In other circumstances, however, it is up to the discretion of the individual organization
whether NPs can perform these activities.
SECTION 2: STANDARDS
APPLYING STANDARDS TO PRACTICE
• NPs are expected to practice according to:
• Nurse practitioner practice standard
• CNO standards and guidelines
• Relevant laws
The Nurse Practitioner practice standard outlines the expectations that are unique to NP practice. NPs
are also accountable to practise according to other CNO practice documents and relevant laws. The
following scenario shows how NPs apply various standards and guidelines to their practice.
SCENERIO: APPLYING STANDARDS TO PRACTICE

• When would Joe use:
• The Nurse practitioner practice standard
• The documentation standard
• The confidentiality and privacy- Personal health information standard
• The consent guideline
Joe is an NP at a community clinic. When would he use the following practice standards?
• the Nurse Practitioner practice standard
• the Documentation standard
• the Confidentiality and Privacy—Personal Health Information standard
• the Consent guideline
Joe would use the accountabilities that are set out in the Nurse Practitioner practice standard when he
assesses a client, diagnoses a health condition and prescribes medication. Joe applies the
Documentation standard when documenting his assessment findings, diagnosis and treatment plan. Joe
refers to the Confidentiality and Privacy—Personal Health Information standard whenever he shares
information about a client’s health condition. Joe uses the Consent guideline if he has questions about
getting informed consent from a client for a treatment plan. It is important to note that multiple
standards often apply to any given situation. For example, Joe also uses the Therapeutic Nurse‐Client
Relationship standard, Professional Standards, and the Ethics and Privacy standard when doing all of
these things.
PROTECTED TITLES
• Nursing titles are protected
• Only registered nurse can use the title” nurse”
• Only Nurse Practitioners can use “NP” or “RN(EC)” in their practice
In Ontario, the titles “nurse,” “Registered Nurse,” “Registered Practical Nurse” and “Nurse Practitioner”
are protected by the Nursing Act, 1991. This means that CNO has the authority to restrict the use of
these titles, and that only members of CNO have the right to use them. Additionally, only Registered
Nurses in the Extended Class can use the title Registered Nurse in the Extended Class, Nurse
Practitioner, or NP.
ADDING SPECIALITY CERTIFICATE

• Every NP has at least one specialty certificate
• Nurse Practitioner- Primary Health Care
• Nurse Practitioner- Paediatrics
• Nurse Practitioner- Adult
All NPs have one or more specialty certificates. The specialty certificates are Nurse Practitioner‐ Primary
Health Care, Nurse Practitioner‐Paediatrics and Nurse Practitioner‐ Adult. The specialty certificates refer
to a specific client population. They do not refer to an area of clinical focus (such as cardiology) or a
practice sector (such as acute care or home care). NPs may work in any sector or setting, but they can
only provide health care services to the client population related to their specialty certificate. So an NP
with an Adult specialty certificate may provide health care services to clients who range in age from late
adolescence to older adulthood. An NP with a Paediatrics specialty certificate may provide health
services to clients who range in age from neonates to late adolescence. And an NP with a Primary health
care specialty certificate may provide health services to clients of all ages.
CLIENT POPULATION
• NPs
• Work with their employer to clarify their role and professional accountability
Employers will determine which specialty certificate is needed for a specific role. Therefore, it is
important that NPs discuss with their employers the expectation that they only treat that population.
They must also make sure other members of the health care team (and if necessary, a client) know and
understand that they must limit their practice. It is the NP’s responsibility to ensure the client and other
members of the health care team are aware of their specialty certificate. The following scenario shows
how this can be done
SCENERIO: SPECIALTY CERTIFICATES

• Susan is an NP with a Paediatrics specialty certificate. Susan is about to start a new job in a
community sexual health clinic.
Susan is an NP with a Paediatrics specialty certificate. Susan is about to start a new job in a community
sexual health clinic. How can Susan provide clarity on her role within her new team, and make sure she
limits her practice to a client population consistent with her specialty certificate?
Susan meets with her hiring manager before starting her new role and discusses the condition that she
not provide health services to adults. This way, the manager has realistic expectations about Susan’s
practice. Susan’s manager assigns Susan to the health unit’s adolescent client population. Susan also
meets with her new colleagues to discuss her role.
NP PRACTICE REQUIREMENT
• Clinical practice
• With clients appropriate to the specialty certificate
• Involving health assessment. Diagnosis and therapeutics.
• Demonstrate NP competencies
To maintain registration in the Extended Class, NPs must maintain competency in clinical NP practice.
This clinical practice must include direct interaction with the client population of the specialty certificate
that the NP holds. The clinical practice must also include the use of advanced nursing knowledge and
decision‐making skill in the health assessment, diagnosis and therapeutic treatment of those clients.
During Annual Membership Renewal, when nurses renew their registration with the College, NPs are
asked to declare if they have met the clinical practice requirement within the previous three years. If
they do not meet this requirement, they are not eligible to remain registered in the Extended Class and
can no longer practice an NP’s extended scope of practice. NPs are also expected to demonstrate the NP
competencies that apply to their practice.
Section 3: Health assessment and diagnosis

• Purpose of health assessments
• Determine health status
• Evaluate response to treatment
• Make a diagnosis
• Health assessments may include
• Client history
• Physical exam
• Chart review
• Test results
• Information from other sources
NPs incorporate evidence‐based knowledge with advanced assessment skills to obtain information
necessary to identify client diagnoses. They perform health assessments for a variety of reasons. These
include determining a client’s overall health status, evaluating a client’s response to treatment and
making a new diagnosis. NPs use information from multiple sources to inform their client assessment.
These may include a client health history, physical exam, chart review, assessment findings from other
health professionals, results of relevant tests or procedures, and, with client consent, information from
family, friends or other caregivers.
TYPES OF ASSESSMENT
• Conduct a comprehensive or focused assessment as appropriate
• Adapt assessment technique to individual client
• Identify urgent, emergent, and life-threatening situations
NPs use their knowledge, skill and judgment to assess the needs of a particular client. This includes
whether a comprehensive or focused assessment is required. They adapt their assessment techniques
and tools to fit each client’s needs. NPs look for and identify urgent, emergent and life‐ threatening
situations when assessing clients. The following scenario shows how NPs can apply these principles to
their practice
SCENERIO: ASSESSMENT
• A 25-year-old client with a fractured arm from a skateboarding accident
• An 88-year-old client with a fractured arm and a history of frequent falls
Two clients arrive at a clinic. Both have fractured arms. One client is a 25‐year‐old woman who fractured
her arm in a skateboarding accident. The other client is an 88‐year‐old man who fractured his arm in a
fall and has a history of frequent falls. What kind of assessment would you give each client?
SCENERIO: ASSESSMENT
• A 25-year-old client with a fractured arm from a skateboarding accident: Focused assessment
• An 88-year-old client with a fractured arm and a history of frequent falls: Comprehensive
assessment
The 25‐year‐old client would generally require a focused assessment—provided no other risk
factors are identified during the client interaction. The 88‐year‐old client will likely require a
more comprehensive assessment
DIAGNOSIS
• Consider differential diagnosis
• Establish probable diagnosis
• Communicate to client
• Diagnosis
• Relevant clinical information
• Treatment plan
• Expected outcomes and prognoses
• Verify client understands the information
NPs are engaged in the diagnostic process. They develop differential diagnoses through
identification, analysis, and interpretation of findings from a variety of sources. Before
communicating a new diagnosis to a client, NPs rule out the various differential diagnoses that
are relevant to the client’s clinical presentation. Once determined, NPs communicate to the
client the diagnosis, all relevant clinical information, treatment plans, and expected outcomes
and prognoses. It is essential for the NP to verify that the client understands this information.
This provides clients with the information needed to make informed choices about their plan of
care.
ORDERING TESTS
• Have a reliable system for receiving test results
• Communicate clinically significant results and implications in a timely
manner
• Arrange appropriate follow-up
When ordering tests, NPs are accountable for a number of things. They must make sure there is
a reliable process in place for a qualified professional to review test results in a timely manner
and provide the appropriate follow‐up care. In most cases, the NP who orders the test will be
the one to review the result. However, in some practice settings, the NP who orders the test
may not be the professional who follows up. Sometimes, clients may not follow through on tests
the NP orders. NPs are accountable for ensuring that clients have the necessary information to
make informed decisions about tests. When possible, NPs should follow up to explore the
client’s reasons for not taking the test.
SCENARIO: Ordering tests
• Marion has ordered a chest X-ray for a client
The following scenario demonstrates the accountabilities of NPs when ordering tests. Marion,
an NP, provides care to residents in a long‐term care home. Marion is going on vacation
tomorrow. She has ordered a chest X‐ray for a client but will not receive the results before she
leaves. What should Marion do?
SCENARIO: Ordering tests
• Arrange for cover
• Establish process
Marion arranges with her colleague Tim, who is also an NP, that he will cover her while she is
away. They’ve both worked with their employer to establish a clear process for transfer of
accountability during vacations. The process includes a log of tests ordered for all residents.
With this process in place, Marion feels comfortable ordering the X‐ray because she knows Tim
will review the results and follow up appropriately.
Section 4: Therapeutic management

• When selecting appropriate treatment, consider
• Findings from assessment, diagnosis, and history
• Client preference
• Determinants of health
Also,
• Use evidence-informed practice
• Collaborate with client
• Arrange for monitoring and follow up
Therapeutic management includes both pharmaceutical and non‐pharmaceutical therapies and
procedures that NPs order. NPs provide them to maximize the client’s health and wellness
potential. Since every person is different, the most appropriate plan of care for clients with the
same clinical presentation may differ. Considerations or contexts that will inform the plan of
care include the results of the health assessment and a best possible medical history, the client’s
preferences, and social determinants of health. NPs use their knowledge, skill and judgment to
assess the client’s individual needs. They use current evidence, taking into consideration what is
appropriate and relevant to their practice setting. They also collaborate with the client and the
client’s family to reduce the risk of harm. They implement strategies for appropriate monitoring
and follow‐up.
Prescribing overview
• Medication history
• Prescription = order for medications
• Evidence that medication is appropriate
• Client education
• Harm reduction strategies
• Monitoring and follow-up
Prescribing medication is a common part of NP practice. It is part of a continuum, beginning with

the NP’s assessment of a client’s needs. This includes completing a best possible medication
history and leads to a treatment plan. A prescription, also known as an order, provides a
pharmacist and other care providers with the authorization and specific instructions for
dispensing or administering a medication to a client. When NPs prescribe, they are accountable
for using evidence to decide a number of things: that the client requires the medication, that it
is a safe and effective treatment, and that it aligns with the client’s care preferences. NPs must
provide education to the client about the medications prescribed, including why they are
receiving it, how much it will cost, the possible side effects, contraindications and precautions,
and next steps. NPs should also ensure that there is an appropriate follow‐up and monitoring
plan that works for the client.
Prescriptive authority
• Most medications and therapeutic substances
• Only NPs who’ve completed approved education can prescribe controlled substances
In Ontario, NPs have broad legal authority to prescribe most medication and therapeutic
substances, including substances for administration, such as oxygen or blood products. Only NPs
who have successfully completed the College’s controlled substances education requirement
can prescribe controlled substances. You can find out if a nurse has completed the necessary
education on our public Register, Find a Nurse. There are a few controlled substances that NPs
are prohibited from prescribing due to federal legislation.
Reasons for prescribing

• Must be for therapeutic purposes
• Health and quality of life
• Treating conditions
• Preventing illness
• Meeting the client’s goals
NPs only prescribe medication to clients for therapeutic purposes. “Therapeutic purposes” is a
broad term that includes prescribing medication for a legitimate reason to maximize client
health and wellness. This includes promoting health and quality of life, treating health
conditions, preventing illness and meeting client goals, such as symptom management.
Scenario: Prescribing
The following scenario demonstrates some of the different factors and circumstances that
would affect an NP’s decision to prescribe a medication: Richelle, an NP, worked in an
outpatient diabetes education centre for several years. She joined a heart failure clinic eight
months ago. Andrea, a client, presents with comorbidities, including type 2 diabetes. When
reviewing the health record, Richelle notes that Andrea has a recent random blood glucose level
of 15.2. When discussing this, Andrea says her levels have been running between 11 and 17. She
asks Richelle to adjust her medication to get her blood sugar under control since she missed her
recent diabetes clinic appointment. Richelle verifies the medications that Andrea is taking to
control her blood glucose. After assessing Andrea, she notes that she is asymptomatic. What
should Richelle do?
Decision to prescribe
• Concepts that apply
• Knowledge, skill, and judgement
• Continuity of care
• Practice- setting factor
• Client-specific factor
Richelle has the knowledge, skill, and judgment to adjust Andrea’s diabetes medication.
However, she recognizes that Andrea requires continuity and team‐based care to manage her
diabetes. Andrea’s condition, other than the hyperglycemia, is stable, so Richelle explains to
Andrea that it is in her best interest to obtain follow‐up from the diabetes clinic. She provides
health education to Andrea about her nutrition, activity levels and the importance of regular
follow‐up with her diabetes team. She then works with Andrea to contact the diabetes clinic to
arrange appropriate follow‐up with an appointment the same week
What must a prescription include?
• Client’s name and address
• Current date
• Name of medication
• Strength of medication, if applicable
• Dose, route and frequency
• Duration of therapy, if applicable
• Quantity of medication
• Number of refills, if applicable
• Quantity of medication
• Number of refills, if applicable
• Any special instructions
• NP’s name, signature, protected title, registration number, business address and phone
number
A prescription is a form of communication between a prescriber and a person dispensing or

administering medication. To ensure clear communication, the law requires that prescriptions
include information that the pharmacist needs for dispensing, and that the client needs for
taking the medication safely and effectively. NPs must ensure their prescriptions include:
• the client’s name and address
• the date the prescription was written
• the name of the medication
• if applicable, the strength of the medication
• directions for use, including the dose, route of administration and frequency, and if
applicable, the duration of therapy
• quantity of medication
• if applicable, the number of refills
• any special instructions
• the NP’s name, signature, protected title, registration number, business address and phone
number.
NPs must include a copy of the prescription, or document the particulars of the prescription, in
the client’s health record.
Section 5: Other medication practices
Overview
• Legal requirement and restrictions
• Dispensing
• Selling
• Compounding
Regulations under the Nursing Act, 1991, list legal requirements and restrictions that NPs must
comply with when they dispense, sell or compound medications. You can find these listed in
Table 1 of the Nurse Practitioner practice standard. This section of the webcast will focus on
dispensing medications, as selling or compounding medication is not a common part of NP
practice.
What is dispensing?
• Selecting, preparing, and transferring a prescribed medication for administration at a
later time
Dispensing is selecting, preparing, and transferring one or more prescribed medication doses to
a client or a client’s representative for administration at a later time. Dispensing differs from
administration because the drug is not immediately taken by the client. NPs can order
medication to be dispensed by another health care professional who has the legal authority to
perform the controlled act (such as a pharmacist). Most medication dispensing in Ontario is
done by pharmacists.
Circumstances for dispensing
• NPs may only dispense when:
• They (or a member of their team) have prescribed the medication
And one of the following is true
• It is difficult for client to access a pharmacy
• Client wouldn’t otherwise receive the medication
• Client can’t afford to obtain the medication elsewhere
• Medication is for testing the client’s response to treatment
NPs may only dispense medication that they, or a colleague on their health care team, has
prescribed. NPs can’t dispense medication prescribed by a health care professional who is not
part of their immediate team. Additionally, NPs are only authorized to dispense medication
when their client assessment leads them to determine that one of the following are true:
• the client does not have reasonable or timely access to a pharmacy
• the client would not otherwise receive the medication
• the client does not have the financial resources to obtain the medication elsewhere
• the medication is dispensed as part of a health promotion initiative, or
• the medication is dispensed to test the client’s therapeutic response to the treatment.
When one or more of these circumstances occur, an NP has the authority to dispense a
medication. If none of these circumstances are present for a specific client situation, the NP is
not authorized to dispense.
Scenario: Dispensing
The following scenario demonstrates some of the different factors and circumstances that
would affect an NP’s decision to dispense a medication: Carmen is an NP at a university student
health clinic. Her practice includes dispensing free oral contraceptives to sexually active clients
who can’t afford to purchase the medication. During an appointment to review immunizations,
she sees a client, Beth. Beth presents Carmen with a prescription for birth control pills that her
family doctor prescribed. Carmen assesses Beth and determines that Beth has insurance
coverage for medications, has one month’s worth of the medication from an earlier prescription
and can obtain the medication from a local pharmacy. Based on this, can Carmen dispense
Beth’s birth control pills?
Scenario: Dispensing
• Carmen advises Beth that she cannot dispense the medication for her
Carmen determines that Beth’s situation does not meet any of the circumstances for NP
dispensing. Therefore, Carmen advises Beth that she cannot dispense the medication to her.
Packing and Labelling
• Medication must:
• Meet the client’s needs
• Be labeled with complete information
• NPs must:
• Document when dispensing
• Provide medication directly to the client
When dispensing, the package and label must meet certain requirements. The medication must be
in a container that meets the needs of the client, maintains the integrity of the medication, and is
labeled with the information the client will need to properly use and store the medication.
Additionally, NPs are responsible for documenting the reason for dispensing the medication and
providing the medication directly to the client or client's representative.
What must a label include?
• Client’s name
• Date dispensed
• Name of the medication
• Strength of medication, if applicable
• The dose, route of administration and frequency
• Duration of therapy, if applicable
• Quantity of mediation dispensed
• Expiry date
• Special instructions
• NP’s name, protected title, business address and phone number
To assist clients in taking medication safely, the Nursing Act, 1991, lists the information that
must be included on the label of any medication that an NP dispenses. These are:
• the client’s name
• the date the medication was dispensed
• the name of the medication
• if applicable, the strength of the medication
• the dose, route of administration and frequency the client must take it
• if applicable, the duration of therapy
• the quantity of medication dispensed
• the expiry date
• any special instructions that the client needs to know about taking or storing the
medication
• the NP’s name, protected title, business address and phone number. Depending on an
NP’s practice setting, medications dispensed to clients may also have identification
numbers. The name of the medication manufacturer must also be added to the label if the
NP has the information. This helps with tracing the medication to a client if there is a
medication recall.
Section 6
Controlled substances
What are controlled substances
• Restricted by federal law
• Types:
• Narcotics
• Controlled drugs
• Benzodiazepines and targeted substances
• Cannabis
• High risk of misuse, addiction, and diversion
Controlled substances are medications restricted by federal law under the Controlled Drugs
and Substances Act. They include narcotics, such as morphine and other opioids, controlled
drugs such as testosterone and methylphenidate, benzodiazepines, and targeted substances
such as lorazepam and diazepam, and cannabis, including dried marijuana and cannabis oil.
These medications are restricted because they present a high risk of misuse, addiction, and
diversion. Controlled substances are used to treat a wide variety of conditions including (but
not limited to) pain, anxiety, and attention‐deficit and sleep disorders.
Controlled substances authority

• NPs who have completed CNO’s education requirement can prescribe
• NPs are not authorized to prescribe:
• Coca leaves ( cocaine, opium, belladonna suppositories
• Anabolic steroid (except testosterone)
Only NPs who’ve completed CNO‐approved education can prescribe controlled substances.
NPs are prohibited from prescribing a few controlled substances. These medications are
restricted at a federal level. They are heroin, coca leaves such as cocaine, opium and
belladonna suppositories, and anabolic steroids other than testosterone.
Additional legal requirements and restrictions on controlled substances
• NPs are not authorized to sell controlled substances
• Specific information must be included on a prescription
• Specific requirement for fentanyl patches
• Refills and verbal orders
• Medical marijuana document
NPs are not legally authorized to sell controlled substances. The Ontario government
monitors the prescribing and dispensing of medications that pose a high risk of misuse,
addiction and diversion. These monitored medications have additional prescription
requirements. Monitored medications include all controlled substances, as well as opioids
that are not controlled substances, such as medications containing Tramadol. On a
prescription for monitored medications, NPs must include a client identification number
from an acceptable identification listed by the Ontario government, for example, a health
card number. There are specific requirements for dispensing fentanyl patches including the
information NPs must provide on a prescription to the dispenser. There is information in the
Nurse Practitioner practice standard, and on the CNO website about this and other legal
requirements and restrictions. These include when refills are allowed, whether a verbal (for
example, over the telephone) prescription can be provided, and requirements for
completing a medical marijuana document. If you have questions about the proper storage,
record keeping and reporting of controlled substances, the Office of Controlled Substances
at Health Canada is a good resource.
Controlled substances standards
• Therapeutic management expectations
• Additional expectations
• Consider other available treatment options
• Limit quantity prescribed
• Use evidence-informed strategies to manage risks
• Monitor clients regularly
The standards about therapeutic management apply to all medications. However, there are
additional expectations for controlled substances. This is because these medications are
associated with unique risks for misuse, addiction and diversion. These expectations include:
considering other available treatment options, limiting the quantity prescribed, using
evidence‐informed strategies to manage misuse, addiction and diversion, and monitoring
clients regularly. NPs are expected to use appropriate evidence to make clinical treatment
decisions, for example, about risk factors and dosing associated with a particular controlled
substance.
Scenario: Controlled substances

The following scenario demonstrates how an NP can apply these expectations when
considering whether to prescribe a controlled substance.
Jeannine is an NP working in an emergency department. She is assessing and treating a
client with a fracture following an accident. This client is in severe pain, which is limiting the
client’s function. Jeannine is authorized to prescribe controlled substances and is
considering prescribing an opioid to manage the client’s pain. How should Jeannine
proceed?
Scenario: Controlled substances

• Screens for risk factors
• Completes best possible medication history
• Uses evidence
• Arranges follow up
• Provides information to client
Jeannine screens for risk factors associated with possible substance misuse.
She completes a best possible medication history which indicates that this client is not on
any medication. Using the evidence, she identifies that an opioid is indicated for treatment
of acute pain for this client situation.
Jeannine prescribes a three‐day course of opioids. She also makes arrangements for the
client to be seen by their primary care provider in two days to reassess the pain
management plan.
Jeannine contacts the outpatient pharmacy and transmits the prescription directly to the
pharmacy. Finally, Jeannine counsels the client about safe use of the medication
More information
• Authority and restrictions
• Practice resources
• Membership info
• Practice Q&As
This concludes the Nurse Practitioner practice standard webcast. More information about
the authority and restrictions on NP practice, as well as additional practice resources,
membership information, and our NP practice
Nurse Practitioner
Introduction
The College of Nurses of Ontario’s (the College’s) standards inform nurses of their accountabilities and
the public about what to expect of nurses. These expectations contribute to public protection and are
the benchmark for how a competent nurse should perform.
This Nurse Practitioner practice standard describes the accountabilities specific to Nurse Practitioners
(NPs) in Ontario (also known as Registered Nurses in the Extended Class). NPs are also accountable for
complying with relevant laws and other College standards and guidelines1 as applicable.
NPs are Registered Nurses who have met additional nursing education, experience and exam
requirements set by the College. Only those registered with the College in the Extended Class can call
themselves “Nurse Practitioner” or “NP”.
NPs are authorized to diagnose, order and interpret diagnostic tests, and prescribe medications and
other treatments for clients. NP practice includes health promotion with the aim of optimizing the
health of people, families, communities and populations. This enables NPs to practice with diverse client
populations in a variety of contexts and practice settings such as acute care, primary care, rehabilitative
care, curative and supportive care, and palliative/end-of-life care.
The College registers NPs with one or more of the following specialty certificates:
■ Nurse Practitioner–Primary Health Care (NP-PHC)
■ Nurse Practitioner–Pediatrics (NP-Pediatrics)
■ Nurse Practitioner–Adult (NP-Adult).
Each specialty certificate refers to a specific client population and not a clinical area or a practice sector.
The College does not restrict the clinical areas or sectors in which NPs work.
Scope of practice
The Regulated Health Professions Act, 1991 (RHPA) and Nursing Act, 1991 set the legal framework for
the practice of nursing. This includes a scope of practice statement and a number of controlled acts NPs
are authorized to perform.
Nursing scope of practice statement

The following statement applies to all nurses: 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 (Nursing Act, 1991).
Controlled acts
Under the Nursing Act, NPs are authorized to perform the following controlled acts:2
1. Communicating to a client, or a client’s representative, a diagnosis made by the NP.

3. Putting an instrument, hand or finger:
i. beyond the external ear canal;
ii. beyond the point where the nasal passages normally narrow;
iii. beyond the larynx;
iv. beyond the opening of the urethra;
v. beyond the labia majora;
vi. beyond the anal verge; or
4. Applying and ordering the application of a prescribed form of energy.
5. Setting or casting a bone fracture or joint dislocation.
7. Prescribing, dispensing, selling or compounding a medication.
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.
Other authorized activities

NPs have the authority to order and apply specified tests. For the most up-to-date list, please visit our
website at www.cno.org/np.
Standards
This section describes standards for NP practice.
NPs:
■ practise according to College standards, guidelines, and relevant laws.
■ use the protected title “Nurse Practitioner” (NP) or “Registered Nurse Extended Class” (RN(EC)), and
may add their specialty certificate(s) to their title.
■ maintain competence in clinical NP practice. This clinical practice must include the use of advanced
nursing knowledge and decision making skill in health assessment, diagnosis and therapeutics when
treating clients appropriate for the NP’s specialty certificate.
■ demonstrate the NP competencies applicable to their practice.
■ limit their practice to clients appropriate for their specialty certificate.

Health Assessment
NPs integrate an evidence-informed knowledge base with advanced assessment skills to obtain the
information necessary for identifying client diagnoses, strengths and needs.
NPs:
■ conduct a comprehensive or focused health assessment as appropriate to the individual client’s

presentation.
■ perform procedures for client assessments.
■ obtain and consider the necessary information for the health assessment.
■ identify urgent, emergent and life-threatening situations.
Diagnosis
NPs are engaged in the diagnostic process and develop differential diagnoses through identification,
analysis, and interpretation of findings from a variety of sources.
NPs:
■ consider the differential diagnoses and establish the probable diagnoses.
■ order appropriate tests.
■ perform appropriate procedures.
■ arrange appropriate follow-up of test results; implement reliable systems for test results to be
received and communicated in a timely manner, and work with organizations in which they practice to
implement such systems.
■ communicate clinically significant results, and their implications, to the client and other health
professionals as appropriate.
■ communicate diagnoses to the client, including discussing relevant clinical information, treatment
plans and the expected outcomes and prognoses.
■ verify that the client understands information related to relevant findings and their diagnoses.
Therapeutic Management
NPs, on the basis of assessment and diagnosis, formulate the most appropriate plan of care for the
client and implement evidence-informed therapeutic interventions in partnership with the client to
optimize health.
NPs:
■ formulate and document a plan of care based on assessment findings, diagnosis and evidence
informed practice.
■ select the appropriate treatments or interventions in collaboration with the client.

■ perform appropriate procedures.
■ stay informed about reliable quality assurance systems in their practice setting and advocate for
reliable systems if there are none.
■ intervene to stabilize the client in urgent, emergent and life-threatening situations.
■ provide pharmacological interventions, treatment, or therapy by:
◗ reviewing the best possible medication history for the client
◗ Selecting pharmacotherapeutic options as indicated by diagnosis based on determinants of health,

evidence-informed practice, and client preference
◗ counselling the client on pharmacotherapeutics, including rationale, cost, potential adverse effects,
interactions, contraindications and precautions, as well as reasons to adhere to the prescribed regimen
and required monitoring and follow-up
◗ completing accurate prescription(s) in accordance with applicable laws
◗ establishing a plan to monitor the client’s response to medication therapy, and continue, adjust or
discontinue a medication based on assessment of the client’s response
◗ applying strategies to reduce risk of harm involving controlled substances, including medication
misuse, addiction, and diversion
■ develop and implement an appropriate follow-up and monitoring plan in collaboration with the client.
Controlled Substances
In addition to the standards for therapeutic management listed above, NPs have other accountabilities
when prescribing and dispensing controlled substances.
Controlled substances are medications that are restricted by the Controlled Drugs and Substances Act
because they present a high risk of misuse, addiction and diversion.
When prescribing controlled substances, NPs:
■ consider the available treatment options (pharmacological and non-pharmacological) based on

available evidence and client circumstances before using a controlled substance in a treatment plan.
■ incorporate evidence-informed strategies for assessing, managing and monitoring the risks of misuse,
addiction and diversion.
■ prescribe a quantity of controlled substances to be dispensed that balances the need to reassess and
monitor the client with the risk of harm that may result if the client runs out of medication. NPs
providing episodic care should prescribe the minimum amount necessary until the client can be assessed
by their regular provider.
■ monitor the client’s response to the prescribed controlled substances after the initial trial and on a
regular basis.
■ inform clients of the unique risks associated with medication misuse, addiction and diversion, and
provide clients with education and strategies for mitigating risk.
■ advise the client on safe use, storage and disposal of controlled substances.
When dispensing controlled substances, NPs:
■ consider the unique risks associated with medication misuse, addiction and diversion,
■ implement strategies to mitigate these risks, and
■ provide clients with education and strategies for minimizing risk.
Medical Cannabis
Medical cannabis is not a controlled substance and differs from conventional medications. It is available
in a variety of strains and formulations that vary in potency and chemical composition. NPs should
exercise caution if they are considering the use of medical cannabis in their patient’s treatment plan.
NPs who complete a written order or medical document authorizing the use of cannabis for medical
purposes are expected to use evidence to inform this treatment decision. NPs must also comply with
cannabis regulations under the Cannabis Act.
NPs are also expected to inform clients about unique risks associated with medical cannabis as a result
of the variability in composition and potency.
Collaboration, Consultation, and Referral

NPs identify when collaboration, consultation and referral are necessary for safe, competent and
comprehensive client care.
NPs:
■ establish collaborative relationships with health care providers and community-based services
■ work with other health care professionals and service providers to develop a common understanding
of the plan of care, communication strategies and individual accountabilities.
■ consult other health care professionals when encountering client care needs beyond the legal scope of
NP practice, their individual competence, or when the client would benefit from the expertise of the
other health care professional(s).
■ review consultation and/or referral recommendations from other health care providers with the client
and integrate these recommendations into the plan of care as appropriate.
■ provide consultation, respond to questions, and clarify orders and the plan of care to other care
providers.
■ provide verbal orders only when they are not able to immediately document the order themselves,
and sign the verbal orders as soon as possible.
Conflict of Interest
NPs recognize and ethically manage actual, potential and perceived conflicts of interest.
NPs:
■ do not use their professional designation to endorse or promote one treatment option over another.
■ must not obtain any personal benefit,3 which conflicts with their ethical duty to clients, as a result of
their NP practice.
■ develop strategies to mitigate the risk that their interactions with industry4 may interfere with
evidence-informed decision-making.
■ do not prescribe medication to themselves.
■ only provide professional services to family members, partners, friends or acquaintances when there
are no other providers available in circumstances outlined in the Therapeutic Nurse Client Relationship
practice standard.
■ only prescribe a controlled substance to a family member, partner, friend or acquaintance to

intervene in an emergency situation and only when there is no other prescriber immediately available.
Discontinuing the NP-client relationship

An NP’s primary obligation is to provide safe and ethical nursing services to clients. Under provincial
law,5 nurses may only discontinue necessary professional services if:
■ the client requests discontinuation
■ alternative or replacement services are arranged, or
■ the client is given reasonable opportunity to arrange alternative or replacement services.
NPs may be required to discontinue their professional relationship with clients when the nurse-client
relationship is eroded to the point where NPs can no longer meet their professional obligations toward
the client.
Discontinuing the professional relationship when the client still requires service and has not requested
discontinuation should be a last resort.
NPs:
■ advocate for employer policies about accepting, treating and discharging clients, that are fair,
transparent and driven by client interest and safety.
■ discuss with the client any issues, as they arise, that impact the NP-client relationship.
■ work with the client to develop and implement strategies for resolving issues impacting the NP-client
relationship wherever feasible.
■ discuss concerns and seek assistance from their employer and other members of the health care
team to assist in addressing issues.
■ communicate to the client the decision to discontinue care, and discuss with the client the reason for
this decision whenever feasible. ■ identify an appropriate alternate provider for the client or allow the
client a reasonable amount of time to find an alternate provider.
■ continue to provide essential health care services, whenever feasible, until another provider has been
identified.
■ document the reason for the decision to discontinue services, including a description of actions taken
to resolve issues prior to the decision
Legal requirements and restrictions

The remainder of this document describes legal restrictions and requirements with which NPs must
comply.
Delegation6
NPs are not authorized to delegate the following controlled acts:
■ prescribing, dispensing, selling or compounding medication
■ ordering the application of a form of energy, or
■ setting a fracture or joint dislocation.
NPs can authorize directives. Information about delegation and directives can be found in the
Authorizing Mechanisms and Directives practice guidelines.
Medical Assistance in Dying7

Federal law allows NPs to provide medical assistance in dying. NPs who participate in medical assistance
in dying must comply with the legal requirements outlined in the College’s document: Guidance on
Nurses’ Roles in Medical Assistance in Dying.
Medication Practices8
NPs:
■ prescribe, dispense, compound, or sell medication, and administer substances by injection or

inhalation, only for therapeutic purposes when there is a professional relationship with the client.
■ are not authorized to sell or compound controlled substances.
■ must not obtain any personal benefit,9 which conflicts with their ethical duty to clients, as a result of
prescribing, dispensing, compounding or selling medication.
■ only dispense, compound, or sell medication when they have reason to believe the medication was
obtained and stored in accordance with applicable laws.
■ only dispense, compound, or sell medication after checking that the medication will not expire before
the client is expected to finish it.
■ must not advertise that they dispense or sell medication, unless they also communicate the specific
circumstances in which they are authorized to do so.10
■ must comply with the legal restrictions and requirements specific to the controlled acts of
prescribing, dispensing, compounding and selling medications outlined in Table 1.
Controlled Substances
NPs who have successfully completed College approved education11 are authorized to prescribe
controlled substances. Under federal law,12 NPs are not authorized to prescribe the following controlled
substances:
■ opium
■ coca leaves, and
■ anabolic steroids except testosterone (NPs are authorized to prescribe testosterone.)
NPs must not authorize directives for controlled substance

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Week 1: Entry-to-practice competencies: for registered nurses

◗ the known risks and benefits to the individual,

◗ the predictability of outcomes of performing the procedure,

◗ other relevant factors specific to the situation; and

◗ an instrument, hand or finger beyond the individual’s labia majora.

◗ the Long-Term Care Homes Act, 2007;

◗ the Child, Youth and Family Services Act, 2017;

◗ the Public Hospitals Act, and

◗ seeking peer input;

◗ developing a learning plan;

◗ implementing the plan; and

◗ evaluating the outcomes of the plan;

• All provinces covered inpatient hospital

• All provinces extended coverage to medical

• Canada Health Act

Ontario Health Team-integrated care delivery systems

Levels of Care: nursing roles

Total Patient Primary

Impact on Patient Outcomes

Week 3: CNO Refusing Assignments and Discontinuing Nursing Services

CNO: Disagreeing with the Care Plan

● Resolving dilemmas caused by conflicting obligations requires thoughtful consideration of all

▪ What are my specific concerns about the patient’s care plan?

▪ What evidence am I applying to the situation?

▪ Am I aware of, and following, relevant organizational policies applying to resolving

▪ Have I communicated my decision to not implement the care plan?

CNO PRACTICE STANDARDS ETHICS

– College of Nurses of Ontario

• interprofessional, involving a variety of health care professionals working together to

This document focuses on three factors—

Many of the concepts in this document apply

The purpose of this document is to:

Legal Scope Of Practice

Nursing’s Scope of Practice Statement

The scope of practice statement for nursing states:

ii. Controlled Acts Authorized to Nurses

putting an instrument, hand or finger

o beyond the external ear canal

treating, by means of psychotherapy technique.

delivered through a therapeutic relationship, an individual’s serious disorder of thought,

Nurses are to Consult if it is beyond your competence

The nurse is accountable for:

 her or his actions and decisions

The Three-Factor Framework

Decisions about the utilization of an RN and an RPN are influenced by:

Client Factors Autonomous RN or RPN RN Involved or Providing

Complexity o care needs well o care needs not well

Predictability o predictable outcomes o unpredictable

Risk of negative outcomes o Unpredictable

Consultation involves seeking advice or information from a more experience or knowledgeable

An important aspect of efficient consultation

Consultation results in one of the following:

Environment Factors More Stable Less Stable

Practice supports clear and identified ■ unclear or unidentified

■ high proportion of expert ■ low proportion of expert

Consultation resources many consultation resources few consultation resources

sedated clients (includes deep sedation and general anaesthesia).