Responding to Complaints at the College of Nurses of Ontario: What Nurses Need to Know
A formal complaint at the College of Nurses of Ontario (CNO) may put a Registered Nurse (RN), Registered Practical Nurse (RPN), or Nurse Practitioner (NP) in a challenging position. With its potential for professional consequences, the complaint process is stressful enough on its own, and nurses who are unfamiliar with the process may experience even more pressure. In light of these difficulties, and based on our experience, we have prepared this introductory guide for nurses responding to complaints at the CNO.
The CNO encloses the complaint in a letter to the nurse and, when applicable, also attaches a summary of any prior decisions involving the nurse. Upon the conclusion of the initial investigation, a panel of the Inquiries, Complaints and Reports Committee (ICRC), comprised of both nurses and public members, receives and reviews the nurse’s file. The ICRC ultimately decides how to address the nurse’s conduct, which in some cases may require ordering further investigation.
With some limited exceptions, such as complaints that are made in bad faith, the CNO generally must investigate and act on all complaints pertaining to nursing care. Only the CNO can determine when it is appropriate to decline an investigation, so regardless of how the nurse feels about the legitimacy of the complaint, they typically should prepare a response. Nurses are obligated to cooperate with the CNO complaint process, which may include participating in interviews.
The ICRC operates the complaint process through the exchange and review of documents rather than as a hearing. This means that the nurse will generally not have an opportunity to explain in person to the ICRC the care they provided or the decisions they made, and can only respond in writing. Prior to submitting their response, the nurse should ensure that they have addressed all of the complainant’s concerns, as a lapse in their account could lead to a negative disposition.
The response is essential to the nurse’s defence, requires time and effort to assemble, and is typically due within 30 days of notification from the CNO. Crafting and submitting the response in this timeframe, amidst concerns of professional consequences and public exposure, can impose a sizable strain on a nurse. Contacting and retaining a lawyer who has experience with professional regulation is a prudent decision that may help the nurse navigate this potentially stressful experience. Legal counsel will assist in preparing the nurse’s response, and typically serves as the first point of contact with the CNO.
When writing their response, the nurse should consider any unique aspects in the case, such as when the care was provided, the complexity of the care, and the possibility of a civil lawsuit arising in relation to the care. Structuring the response as a chronology of any events that are relevant to the allegations is, in our experience, a helpful method for RNs, RPNs, and NPs.
Where a complaint has some merit, it may be appropriate for the nurse to acknowledge this and take responsibility for their shortcoming. In the right circumstances, demonstrating the efforts the nurse has made to reflect, acquire relevant education, and take corrective action may impart the ICRC with confidence that the nurse has learned from the experience and will improve their practice accordingly.
In submitting their finalized response to the investigator, the nurse or, when applicable, their legal representative should generally enclose any relevant records. Under the Personal Health Information Protection Act, 2004, nurses may in some cases qualify as health information custodians for patient records associated with their services, and should consult legal counsel to identify their specific responsibilities. No matter the circumstances, the nurse should always keep their records in compliance with the Nursing Act, 1991 guidelines. Regardless of whether or not the ICRC determines that the care provided was appropriate, it may still evaluate the quality of the nurse’s records.
The investigator receives the nurse’s finalized response, undertakes whatever further investigation it deems necessary, and encloses everything in their report to the ICRC. Once the ICRC determines that it has enough data to inform its decision, it may do any of the following: take no further action; caution the nurse in person before the ICRC; inquire into the nurse’s professional capacity; refer the matter to the Discipline Committee; or take any other appropriate action. With the exception of cases resulting in referrals to discipline or to the Fitness to Practice Committee, the nurse typically receives written reasons for any decision.
The CNO is generally making its regulatory findings more transparent, meaning that, in addition to the risk of professional consequences, complaints now have the potential to open the nurse to public scrutiny. Details of the following ICRC dispositions are posted on the CNO’s Public Register: Specified Continuing Education or Remediation Programs (SCERP); oral cautions; and referrals to discipline. The public will likely see this information on the nurse’s public profile.
Complaints of a more serious nature may compel the ICRC to impose an interim order on the nurse in question. Interim orders are limitations, terms, conditions, or restrictions designed to address concerns of the ongoing harm that could arise from the nurse’s practice. An interim order, which may rise to the level of licence suspension, can last for the duration of the investigation. Further, under section 75 of the Health Professions Procedural Code, the Registrar has the power to appoint a special investigator for more serious complaints. The scope of this section 75 investigation is much broader than in the standard process.
In contrast, complaints of a comparatively less serious nature may be referred to the CNO’s confidential Alternative Dispute Resolution (ADR) process. Nurses who are accused of serious allegations of professional misconduct, including sexual abuse, dishonesty, or fraud, are not eligible for ADR. Referral to ADR generally occurs early in the complaint investigation process, and only proceeds on the consent of both the nurse and the complainant. The parties typically do not meet during this process, as a CNO appointed facilitator speaks separately with the nurse and the complainant about the complaint and how it may be resolved. One of the goals of ADR may be to encourage reflective practice, which asks the nurse to consider their actions and learn from the experience. In complaints in which multiple unidentified nurses are involved, the facilitator may suggest that a group of nurses from the relevant healthcare facility receive a presentation on nursing standards. A settlement position reached through ADR is not final until ratified by the ICRC. If ADR is unsuccessful, the nurse’s matter proceeds through the standard complaint process.
Decisions of the ICRC are generally reviewable before the Health Professions Appeal and Review Board (HPARB). At the request of the nurse or the complainant, HPARB considers whether the CNO’s investigation was adequate and whether the ICRC’s decision was reasonable. All documents and information obtained by the CNO during the complaint investigation stage are available to HPARB, and a package containing the same material is typically disclosed to the nurse and the complainant.
Preparing a written response to the CNO is an important part of dealing with a complaint. Registered Nurses, Registered Practical Nurses, and Nurse Practitioners should consider obtaining the services of lawyers who can help craft their responses and navigate the complaint process in general. RNs, RPNs, and NPs should handle all complaints carefully and responsibly, as a negative outcome has the potential to impact their careers.
Josh Koziebrocki, is the principal lawyer and founder of Koziebrocki Law. He represents numerous nurses and has extensive experience dealing with regulatory issues. He can be reached at 416-925-5445.
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