March 08, 2018

Ensuring client safety: Assessment and care transitions

The College is seeing an increase in the number of nurses who are not performing ongoing client assessments at the frequency needed to ensure client safety. This pattern emerges when we review cases in which clients are exposed to risk.

Ongoing client assessments are critical to providing safe client care. Assessment is a professional accountability and an essential part of your nursing practice, as outlined in Professional Standards, Revised 2002.

All nurses are expected to regularly assess clients. However, certain clients may require more frequent assessment. For example...

The College is seeing an increase in the number of nurses who are not performing ongoing client assessments at the frequency needed to ensure client safety. This pattern emerges when we review cases in which clients are exposed to risk.

Ongoing client assessments are critical to providing safe client care. Assessment is a professional accountability and an essential part of your nursing practice, as outlined in Professional Standards, Revised 2002.

All nurses are expected to regularly assess clients. However, certain clients may require more frequent assessment. For example, if you work with clients who have acute mental illnesses, frequent checks are essential because there are unique safety issues for these clients, which may include an increased risk of violence, self-harm and suicide. Some of these clients may be isolated, require restraints or have a limited capacity to advocate for themselves. Frequent monitoring supports client safety. Clients who are classified as being high risk may require monitoring as frequently as every 15 minutes.

Communication is key

Another source of risk to clients is the potential loss or miscommunication of client information during the transfer of care or handover. Care transitions happen often, such as when a client experiences a change in health care providers or location, when a shift ends or you take a break. Each time, you must communicate client-specific information to a colleague that is clear, focused and comprehensive.

Work with your health care team to establish and maintain effective communication. Be sure to consider:

  • What are the potential risks to my clients?

  • How can I clearly and effectively communicate client information between health care providers in our practice setting?

  • Is this communication sufficient to minimize risk for my clients?

  • Is this communication sufficient to facilitate the continuity of care?

  • How does our current practice contrast with best practice evidence?

Using effective communication strategies to meet the therapeutic needs of your client is one of your accountabilities, as outlined in Therapeutic Nurse-Client Relationship, Revised 2006. This also applies during care transitions.

Shared accountability

The Professional Standards practice standard states that you must facilitate, advocate and promote the best possible care for clients. You must also take action if client safety and well-being are compromised. Therefore, if you have concerns about your ability to perform ongoing assessments appropriate for your practice, speak to your clinical manager and ask your team for support.

If you are a nurse in an administrator role, work with your team to develop policies for a safe work environment in the best interest of clients and professional practice. All members of the health care team have a shared accountability to advocate for a quality practice environment that supports nurses’ ability to provide safe and effective care.

Understand the standards

Practice standards outline the expectations for nurses that contribute to client safety. Practice guidelines, which often address specific practice-related issues, help nurses understand their responsibilities and how to make safe and ethical decisions in their practice.

Would you like to better understand the standards and how to apply them to your practice? We can help! Check out our tools and resources page, as well as Ask Practice, which answers your most frequently asked practice questions. You can also contact our Practice Support team with any practice question by filling out our Practice Support form.

About CNO

The College of Nurses of Ontario (CNO) is the regulator of the nursing profession in Ontario. It is not a school or a nursing association. CNO acts in the public interest by:

  • assessing qualifications and registering individuals who want to practice nursing in Ontario.
  • setting the practice standards of the profession that nurses in Ontario are expected to meet.
  • promoting nurses' continuing competence through a quality assurance program.
  • holding nurses accountable to those standards by addressing complaints or reports about nursing care.

The College was founded in 1963. By establishing the College, the Ontario government was acknowledging that the nursing profession had the ability to govern itself and put the public's well-being ahead of professional interests.

For the latest information, please see our Nursing Statistics page.

Anyone who wants to use a nursing-related title — Registered Nurse (RN), Registered Practical Nurse (RPN) or Nurse Practitioner (NP) must become a member of CNO.

Frequently Asked Questions

Go to the public Register, Find a Nurse, to conduct a search for the nurse. Contact us if you can't find the person you are looking for.

All public information available about nurses is posted in the public Register, Find a Nurse, which contains profiles of every nurse in Ontario. Publicly available information about nurses include their registration history, business address, and information related to pending disciplinary hearings or past findings.

Unregistered practitioners are people who are seeking employment in nursing or holding themselves out as being able to practice nursing in Ontario, but who are not qualified to do so. They are not registered members of CNO. Only people registered with CNO can use nursing-related titles or perform certain procedures that could cause harm if carried out by a non-registered health professional. CNO takes the issue of unregistered practitioners seriously. See Unregistered Practitioners for more information.

To ensure procedural fairness for both the patient (or client) and the nurse, the Regulated Health Professions Act requires that information gathered during an investigation remain confidential until the matter is referred to the Discipline Committee or Fitness to Practise Committee. CNO will not disclose any information that could identify patients (or clients) or compromise an investigation. See Investigations: A Process Guide for more information.

Information obtained during an investigation will become public if the matter is referred to a disciplinary hearing. If a complaint is not referred to a hearing, no information will be available publicly.

See CNO's hearings schedule, which is updated as hearing dates are confirmed. Hearings at CNO are open to the public and the media. For details on how to attend a hearing, contact the Hearings Administration Team.

A summary of allegations and the disciplinary panel outcomes can be found on the public Register, Find a Nurse. Full decisions and reasons are also available.

Where a disciplinary panel makes a finding of professional misconduct, they have the authority to reprimand a nurse, and suspend or revoke a nurse's registration. Terms, conditions and limitations can also be imposed on a nurse's registration, which restricts their practice for a set period. Nurses can also be required to complete remedial activities, such as reviewing CNO documents and meeting with an expert, before returning to practice.

For detailed information see the Sexual Abuse Prevention section.

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