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Introduction

In August 2014, Ontario’s Office of the Fairness Commissioner (OFC) performed a targeted assessment of the way the College of Nurses of Ontario (CNO) registers people who apply for a licence to practise in Ontario, to ensure that the registration practices are fair and continue to improve.

Assessment is one of the Fairness Commissioner's mandated roles under the Regulated Health Professions Act, 1991 (RHPA).

Assessment Cycle

To hold regulatory bodies accountable for continuous improvement, the OFC assesses their licensing practices using a two-year assessment cycle.

Assessment cycles alternate between full assessments and targeted assessments:

  • Full assessments address all specific and general duties described in the RHPA.
  • Targeted assessments focus on the areas where the OFC made recommendations in the previous full assessment.

This approach establishes continuity between the assessment cycles.

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Focus of This Assessment and Report

The August 2014 targeted assessment of the CNO focused on the areas where the OFC made recommendations in the full assessment it completed in August 2012.

The OFC’s detailed report captures the results of the targeted assessment. The assessment summary provides the following key information from the detailed report:

  • duties that were assessed
  • an overview of assessment outcomes for specific-duty practices
  • an overview of comments related to the general duty
  • commendable practices
  • recommendations

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Availability of Report

The OFC encourages the CNO to provide the detailed report to its staff, council members, the public, and other interested parties.

To receive a copy of the detailed report, click here.

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Assessment Methods

Assessments are based on the Registration Practices Assessment Guide – For Health Regulatory Colleges. The guide presents registration practices relating to the specific duties and general duty in the RHPA.

A regulatory body’s practices can be measured against the RHPA’s specific duties in a straightforward way. However, the general duty is broad, and the principles it mentions (transparency, objectivity, impartiality and fairness) are not defined in the legislation.

As a result, the specific-duty and general-duty obligations are assessed differently (see the Strategy for Continuous Improvement of Registration Practices).

Specific Duties

The OFC can clearly determine whether a regulatory body demonstrates the specific-duty practices in the assessment guide. Therefore, for each specific-duty practice, the OFC provides one of the following assessment outcomes:

  • Demonstrated – all required elements of the practice are present or addressed
  • Partially Demonstrated – some but not all required elements are present or addressed
  • Not Demonstrated – none of the required elements are present or addressed
  • Not Applicable – this practice does not apply to this regulatory body

General Duty

Because there are many ways that a regulatory body can demonstrate that its practices, overall, are meeting the principles of the general duty, the OFC makes assessment comments for the general duty, rather than identifying assessment outcomes. For the same reason, assessment comments are made by principle, rather than by practice.

For information about the OFC’s interpretations of the general-duty principles and the practices that the OFC uses as a guideline for assessment, see the Registration Practices Assessment Guide – For Health Regulatory Colleges.

Commendable Practices and Recommendations

Where applicable, the OFC identifies commendable practices or recommendations for improvement related to the specific duties and general duty.

Sources

Assessment outcomes, comments, and commendable practices and recommendations are based on information provided by the regulatory body. The OFC relies on the accuracy of this information to produce the assessment report. The OFC compiles registration information from sources such as the following:

  • Fair Registration Practices Reports, audits, Entry-to-Practice Review Reports, annual meetings
  • the regulatory body’s:
    • website
    • policies, procedures, guidelines and related documentation templates for communication with applicants
    • regulations and bylaws
    • internal auditing and reporting mechanisms
    • third-party agreements and related monitoring or reporting documentation
    • qualifications assessments and related documentation
  • targeted questions/requests for evidence that the regulatory body demonstrates a practice or principle

For more information  about the assessment cycle, assessment process, and legislative obligations, see the Strategy for Continuous Improvement of Registration Practices.

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Assessment Summary

Specific Duties

Specific duties assessed

As a result of the recommendations made in the full assessment completed in August 2012, the CNO has been assessed in the area(s) marked below:

None Unchecked
Information for Applicants Checked
Timely Decisions, Responses and Reasons Unchecked
Internal Review or Appeal Unchecked
Information on Appeal Rights Unchecked
Documentation of Qualifications Unchecked
Assessment of Qualifications Checked
Training Unchecked
Access to Records Unchecked

Outcomes

The CNO is partially demonstrating the practices in the following specific-duty area(s):

  • Information for Applicants
  • Assessment of Qualifications

For practices that are partially demonstrated or not demonstrated, see the Recommendations section later in this summary.

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General Duty

Assessment Method

The CNO selected the method marked below for the assessing of its adherence to the general-duty principles, and informed the OFC:

a. OFC assesses based on the practices listed in the assessment guide Unchecked
b. Regulatory body self-assesses based on the practices in the assessment guide Checked
c. Regulatory body self-assesses using a system-based approach, in which it explains what it does to ensure that its practices are adhering to the general-duty principles Unchecked

Principles assessed

As a result of the recommendations made in the full assessment completed in August 2012, the CNO has been assessed on the principle(s) marked below:

None Unchecked
Transparency Checked
Objectivity Unchecked
Impartiality Unchecked
Fairness Checked

Comments

Since the last assessment, the CNO has taken some measures to ensure transparency and fairness in the registration process. Recommendations for further improvement are described later in this summary.

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Commendable Practices

A commendable practice is a program, activity or strategy that goes beyond the minimum standards set by the OFC assessment guides, considering the regulatory body’s resources and profession-specific context. Commendable practices may or may not have potential for transferability to another regulatory body.

The CNO is demonstrating commendable practices in the following area(s).

Information for Applicants

  • providing information for applicants on its website that is very comprehensive and thorough, including: registration requirements and steps that applicants must take, requirements that may be satisfied through acceptable alternatives, and resources to assist with exam preparation. This information is grouped into three separate sections tailored for applicants educated in Ontario, elsewhere in Canada, and abroad.

Fairness

  • enhancing the information on its website about the reporting requirements and requirements related to applicants’ health and conduct. The “Declaration of Registration Requirements” page has features that allow users to see detailed information about the requirements that are relevant to them.
  • improving processes to reduce the time associated with the initial review and triage of applications by up to 15 weeks.
  • developing and implementing a library of information about educational programs so that applicants from the same nursing program and graduation year are not asked to provide duplicate information about their nursing program.
  • developing an online applicant portal that will allow applicants to track the progress of their application. This will help expedite the CNO’s response to applicant inquiries, many of which are about application status.

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Recommendations

The CNO should improve in the following area(s):

Information for Applicants

Status
  • Clarify how it evaluates international academic credentials. While the CNO states that international academic credentials are evaluated against the Competencies for Entry-Level Registered Nurse Practice, it should clarify exactly how this is done. In particular, it should clarify whether an international program must meet all of these competencies to be considered equivalent to Canadian standards. The CNO should also clarify how this is measured (for example, are all competencies equally weighted?).
Checked
February 2016
  • Clarify how the Objective Structured Clinical Examination (OSCE) – a clinical, competency-based examination – is a valid and reliable measure of academic equivalency.
Checked
March 2015

Assessment of Qualifications

 
  • Be more transparent and explicit about the scoring methodology for the OSCE. The CNO website states that OSCE results “will determine whether the applicant has demonstrated entry-to-practice competencies in order to meet the program requirements.” The CNO should expand on what this means. For example, the CNO should clarify:
Checked
March 2015
  • whether an applicant must obtain a specific threshold score related to each entry-to-practice competency tested by the OSCE. If so, the CNO should state the threshold score required.
Checked
March 2015
  • whether scores for all competencies are averaged or whether an applicant must demonstrate a threshold score for each individual competency. In either case, the CNO should state the threshold score required.
Checked
March 2015
  • whether the CNO accepts OSCE results as submitted by the Centre for the Evaluation of Health Professionals Educated Abroad (CEHPEA) at face value, or whether the CNO conducts its own further evaluation of the results. If the latter, the CNO should clarify the criteria used in its evaluation.
Checked
March 2015
  • Work with relevant stakeholders to develop an integrated approach to bridging education for internationally educated applicants that enables them to address their identified competency gaps. The integrated approach should also address the following:
Checked
March 2015
  • consistent application of nursing educational standards/criteria
Checked
March 2015
  • refining processes and policies to better inform and communicate the educational needs and requirements of applicants
Checked
March 2015
  • processes to verify educational completion
Checked
March 2015
  • evaluation of process effectiveness
Checked
March 2015
  • Ensure that the CNO’s assessment methodology for evaluating an applicant’s OSCE results is clear and consistent. In particular, the CNO should explain its methodology for assessing competency when OSCE results are used to supplement the paper-based competency assessment of academic qualifications.
Checked
March 2015
  • Review its interpretation of the Declaration of Registration Requirements for objectivity, validity and reliability. If deficiencies are found, these should be corrected.
 
  • Review its interpretation of OSCE results for objectivity, validity and reliability. If deficiencies are found, these should be corrected.
 
  • Give applicants more detailed information about their competency gaps in the OSCE, including the specific aspects within each competency where there are deficiencies. 
Checked
March 2015
  • Inform applicants about the criteria for scoring the OSCE. (This recommendation overlaps with the first recommendation in this sub-section).
Checked
March 2015

Transparency

 
  • Establish a process for reviewing registration policies on a regularly scheduled basis.
Checked
March 2015
  • Incorporate visuals into the “Become a Nurse” section of the CNO website in order to enhance clarity.
Checked
February 2016
  • Refine the information in the online registration guides to clarify that applicants can be registered with terms, conditions and limitations if they do not have documentation of Canadian citizenship, permanent residency, or other authorization under the Immigration and Refugee Protection Act (Canada) to practise nursing in Ontario.
Checked
October 2014
  • Include sample scenarios in the information that describes how the CNO evaluates health and conduct.
Checked
March 2015
  • Identify where an applicant may incur costs through a third-party process, including bridging education. The CNO should provide links on its website to any additional information about these processes and their costs.
Checked
March 2015
  • Take measures to show applicants that documented policies have been followed in their case. In particular, this applies to policies concerning timelines for processing applications.
Checked
February 2016
  • Commit to timelines for responding to applicants’ inquiries and communicate the timelines on the CNO website.
Checked
March 2015
  • Be more frank about the specific additional education and/or training requirements for internationally educated Registered Nurse (RN) applicants whose academic credentials are deemed to be not equivalent to Canadian standards. That is, the CNO should communicate to applicants that a separate exam is required (i.e., the OSCE) and that regardless of the number or type of competency gaps identified through this exam, applicants must take bridging education if they wish to remain under consideration for RN licensure. The CNO should also communicate that bridging education must entail university-level courses offered through select institutions and that the courses must be completed as part of an entire bridging program (as opposed to discrete courses, regardless of the competency gaps identified).
Checked
February 2016
  • Inform applicants about the assessment methodology used in grading the OSCE. This includes clarifying:
Checked
March 2015
  • whether applicants need to demonstrate each of the required competencies or whether their performance on all competencies in total is averaged
Checked
March 2015
  • whether there is a minimum threshold for demonstrating the competencies, either individually or averaged
Checked
March 2015
  • what the minimum threshold scores are for demonstrating competencies
Checked
March 2015
  • whether the CNO accepts the OSCE results at face value as they are received by CEHPEA, or whether the CNO performs additional evaluation of the results
Checked
March 2015

Fairness

 
  • In the interest of eliminating or reducing duplication, clarify why the OSCE includes assessment of self-regulation and ethics when applicants are required to complete a separate jurisprudence exam.
Checked
February 2016
  • Demonstrate that the move to the OSCE approach was done through a transparent and impartial process. For example, there was stakeholder consultation, the exam was validated by experts, the questions were tested on recent Canadian BScN graduates, etc.
Checked
March 2015
  • Demonstrate that there either is a current process or a plan to develop a process for evaluating the OSCE for ongoing relevance and necessity as the preferred method of assessing international education credentials that are deemed to be not equivalent to Canadian standards. This could include consideration of the following, for example:
Checked
March 2015
  • how to minimize the differential impact and unintended consequences that result from requiring only internationally educated applicants to take the OSCE
Checked
March 2015
  • whether there are alternative ways to assess the academic credentials of international applicants
Checked
March 2015
Blank = Implementation is in progress.
= Recommendation is implemented.
Acceptable alternative = Regulator implements acceptable alternative to this recommendation.

Assessment History

In the previous assessment, the OFC identified eight recommendations for the regulatory body.

They have all been implemented.

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