[Canada] College of Nurses of Ontario (CNO) vs. Nurses' Health Program (NHP)

[jjj888uuu6]

This thread is concerning monitoring in Ontario, Canada. I have intended this post as a repository of information for Ontario nurses.
 
So, you have received a letter from the College of Nurses of Ontario (CNO) that states that it has received information that indicates you may have a health problem that may be affecting your ability to practice nursing safely. You are given two options: proceed with a CNO health inquiry, or enroll in the Nurses' Health Program (NHP). This is a crossroads, and not much illumination is given. Which to choose? 
 
You may have discovered that there is little anecdotal information online about either of these options. This is because, while there are over 190,000 nurses in Ontario as of this writing (the year 2024), only about 100 per year on average are sent this letter. (This statistic is taken from the annually posted reports of the CNO's Inquiries, Complaints and Reports Committee). You are, unfortunately, part of a very unlucky few. 
 
Having faced this letter myself and having conducted extensive research into these options, I wanted to share my input.
 
The NHP route may at first glance seem more appealing than the CNO route. After all, the NHP is framed as a supportive program intended to help you regain your health. In contrast, the CNO will have you facing something resembling a cold, formal judicial proceeding. 
 
This is a mirage. You should almost always be choosing the CNO route. The NHP route is generally not in your interest.
 
But, before I explain, let's start with some basics. 
 
_____________________________________________
 
A.) The CNO route. 
 
If you choose the CNO route, the CNO will initiate their health inquiry process against you. You will be asked by the CNO's Inquiries, Complaints and Reports Committee (ICRC) to provide an explanation of whatever incident that led to your reporting. Upon providing that, the ICRC, if it feels there are "reasonable and probable" grounds to do so, will send you for an independent medical evaluation (IME) with a CNO-associated physician, to whom you will need to release medical information. This physician will then release their report on you to the ICRC, and at that point you will very likely be referred from the ICRC to the CNO's Fitness To Practice Committee (FTPC). The FTPC's prosecutor will then, with consideration of the IME report, propose terms, conditions and limitations (TCLs) to be applied to your license. TCLs include workplace practice restrictions you must abide by, medical treatments you must undergo, their durations, and more. It is the ultimate role of the FTPC's prosecutor to prove, in a formal hearing with an adjudicative setting, that on a balance of probabilities you need the TCLs they are proposing in order for public safety to be upheld. However, it is actually in the interest of the FTPC's prosecutor to avoid a formal hearing, as this costs time and money, and so they first will attempt to negotiate what is essentially a plea bargain with you. This plea bargain, which is technically called a voluntary undertaking, is analogous to the plea bargains negotiated in criminal proceedings in order to avoid a criminal trial. That is, you and the FTPC's prosecutor will attempt to negotiate on a set of TCLs that you will voluntarily agree to abide by. You can submit medical information from your own treating physician in an attempt to threaten the FTPC's prosecutor into moderating the TCLs of the voluntary undertaking. If the TCLs of the voluntary undertaking are agreed on by both parties, the process ends there. If you and the FTPC's prosecutor cannot agree on the TCLs of the voluntary undertaking, it is then that the matter advances to a formal hearing. If you lose the formal hearing, the TCLs proposed by the FTPC's prosecutor will be unilaterally imposed on you. Almost all referrals to the FTPC end in a voluntary undertaking and do not advance to a formal hearing. 
 
If the FTPC's prosecutor wishes to make changes to your original TCLs after they are initiated – for example, you end up being accused of breaching a TCL and so they wish to increase the severity of other TCLs – they will need to follow the process as described above. This is true whether the original TCLs were initiated by voluntary undertaking or were unilaterally imposed following a formal hearing.
 
From the very beginning of any of these interactions with the CNO, you have the right to be represented by a lawyer. 
 
B.) The NHP route. 
 
If you choose the NHP route, you will be contacted by an NHP case manager. They will interview you, and then will send you for an IME with an NHP-associated physician, to whom you will need to release medical information. This physician will then release their report to the NHP. The NHP's director will then, with consideration of the IME report, unilaterally impose TCLs on you. You will be required to follow them. 
 
If the NHP's director wishes to make changes to these TCLs after they are initiated, they can unilaterally do so at any time and for any reason. You will be required to follow these changes. 
 
If at any point you do not fully cooperate with the NHP's demands, you will be discharged from it and referred to the CNO route. If you disagree with any of the TCLs the NHP's director unilaterally imposes on you, you have only one recourse: to withdraw from the NHP. There is no other recourse; a lawyer will not help you. If you withdraw from the NHP – which you can do at any time, as it is a voluntary program – you will be referred to the CNO route. 
 
_____________________________________________
 
Let's talk about the NHP a little bit.
 
The NHP launched in 2019. It is operated by the Lifemark Health Group. 
 
The NHP is analogous to the "alternative-to-discipline" (ATD) nurse monitoring programs present in almost every state in the United States. There is a lot of anecdotal information online about these ATD programs, including on Reddit and especially on the Recovery subforum of Allnurses.com. Some examples of ATD programs you will commonly hear about are IPN (Florida's), RAMP (New Jersey's), and TPAPN (Texas'). State ATD programs operate fairly similarly to each other. Nurses in the US who are under investigation for their health problems are drawn to these ATD programs because their only other option is to be directly investigated by their state nursing board, a process that will often threaten to scar their licenses with a permanent public mark of discipline and lead to the posting of sensitive and detailed health information for the public to see.
 
If you read the anecdotes concerning these ATD programs, you will quickly learn that they are considered nightmares. There is no oversight. There is no due process. There is no recourse. There is no concern about your health. There is certainly no concern about your finances or livelihood. The only concerns being made are about how strongly public safety can be guaranteed and about how much profit can be made. The treatments prescribed tend to be very excessive, and are pre-determined and blindly applied without taking individual health circumstances into account. The workplace restrictions are draconian and lengthy. Reprisals for breaching an obligation, no matter how trivial, are fierce. You are strongly recommended to read these anecdotes.
 
The NHP is, unfortunately, not very different from these ATD programs. In fact, its design was likely specifically based on them.
 
I would identify two fundamental problems with the NHP route:
 
1.) No oversight; no due process. 
 
The CNO route follows procedure that is outlined by the 1991 Regulated Health Professions Act. This procedure is designed to balance the human rights of the nurse with the duty of the CNO to uphold public safety. Allegations of a breach of this procedure can even be taken to the Ontario judiciary for review. In contrast, the NHP route bypasses the Regulated Health Professions Act completely. Rather, the NHP operates by its own internally formulated policies. It is able to do this because it contextualizes itself as a voluntary program that can be withdrawn from at any time. 
 
In practical terms, this means the CNO route gives you the ability to defend yourself against perceived injustice. The NHP route does not allow this; there is no defence to the perceived injustice, other than to withdraw from the NHP.
 
The ability to defend yourself against perceived injustice is very important. This is because, unfortunately, you are likely to be in receipt of a lot of it, whether you pursue the CNO route or NHP route. Some forms of perceived injustice you are likely to face are:
 
a.) Demands for inappropriate medical treatment: You will likely face TCLs from either the CNO or NHP that include demands to submit to medical treatment of an intensity and duration that you, and, for that matter, any physician not acting as a CNO or NHP evaluator, would consider very excessive. Such medical overtreatment can seriously detrimentally impact your quality of life.
 
b.) Demands for inappropriate practice restrictions: You will likely face TCLs from either the CNO or NHP that include workplace practice restrictions that you and your treating physician believe are harsher than reasonably necessary to uphold public safety. Such practice restrictions can seriously detrimentally impact your livelihood.
 
c.) Demands for inappropriate repercussions in the face of a breach: Whether you choose the CNO or NHP route, you will likely be facing TCLs of many years duration. The NHP sets a standardized five-year program for nurses with substance-related health problems and a standardized three-year program for nurses with other mental health problems. The CNO is a bit more flexible, but aims for about the same durations. These are long periods of time, and during the course of it you may end up breaching your TCLs, either because of a decline in your health status or because of uncontrollable life circumstances that occur without any bad faith on your part. If this happens, repercussions may be demanded by either the CNO or NHP that you and your treating physician believe are harsher than reasonably necessary to uphold public safety.
 
d.) Demands for anything at all: The facts of your case may be such that there is no reasonable justification for TCLs to be applied to your license whatsoever.
 
Because the CNO route provides you with a mechanism to present a defence, it is far likelier it will lead to better outcomes – that is, TCLs with moderated severity, or no TCLs at all – compared to the NHP route. 
 
2.) For-profit interests. 
 
The NHP is formally a non-profit program. Do not let this fool you. The NHP is operated by the Lifemark Health Group, a for-profit healthcare corporation. 
 
ATD programs in the US are well known for operating under for-profit interests. They are also well known for the corrupt practices that stem from these interests. It is in the interest of these ATD programs to enroll you, because your enrollment is the basis for their profiting. Thus, during the intake process, it is regular practice for these ATD programs to carefully comb through your medical history, and as far back as they can access it. They will carefully take note of anything you say. Anything they can find on you – no matter how trivial it is or how far in the distant past it was – can and will be used against you to justify enrolling you. Even if your record is absolutely spotless and no incriminating evidence can be found, they will often still enroll you, under the justification of "just to be safe." 
 
Furthermore, these for-profit interests influence the demands the ATD program makes on you. ATD programs typically profit off you by directing you to undertake medical treatments and satisfy other requirements that are at your own expense and from which the ATD program will financially benefit. 
 
The NHP, unfortunately, acts similarly to these ATD programs in this respect as well. 
 
_____________________________________________
 
Now let's talk about the CNO. 
 
The CNO is, fortunately, considerably more liberal than its state nursing board counterparts in the US. In fact, in the context of health problems it is possibly the most forgiving nursing regulatory body of any province in Canada. The CNO distinguishes clearly between their health inquiry and discipline processes, and so, if they have chosen to initiate the former against you, they have chosen not to discipline you –
even if your health problems have led you to commit serious misconduct in the workplace. The CNO's health inquiry process is confidential other than a vague notation on its public register "Find A Nurse." The notation will be posted once you are referred to the FTPC and will remain until your TCLs expire, upon when it will be removed. Once the notation is removed, an employer will not be able to determine using the public register that you ever faced the health inquiry process or had TCLs applied to your licence. These facts mean that, unlike in the US, there is little incentive for nurses in Ontario to turn to their ATD-equivalent of the NHP. 
 
I would regard the following as the fundamental advantages of the CNO route: 
 
1.) Oversight and due process. 
 
As I have already noted, the CNO, which has oversight from the Ontario judiciary, provides you with due process. Make the best use of it. Get a lawyer. It is absolutely worth it. If you are already aware you will be reported to the CNO but have not been contacted by them yet, you may be able to purchase nurse legal insurance in the interim which will cover your legal costs once you are contacted. In the US, state nursing boards can take up to several years to act on a report. The CNO, in contrast, appears to work quickly. I have heard anecdotes of anywhere in the 1-2 month range between reporting and first contact. In my case, it was even quicker. 
 
If you cannot afford legal counsel, this should not dissuade you. You are still likelier to have a better outcome under the CNO route even if you have no legal representation. 
 
2.) Absence of for-profit interests. 
 
The CNO is a purely non-profit organization. It doesn't have any interest outside of upholding public safety. Of all the health inquiries the ICRC initiates, about 1/4 to 1/3, depending on the year being analyzed, conclude without a referral to the FTPC and so result in no action being taken. (This statistic is taken from the annually posted reports of the ICRC). The ICRC may choose to take no action because the facts that have been presented to it are unlikely to lead to a successful prosecution by the FTPC. However, this is not the only reason. The ICRC may also choose to take no action even in the face of clear evidence of the existence of a health problem, because it makes a determination that the time and costs associated with an FTPC prosecution outweigh the risks to public safety. This may happen if, for example, there is no evidence of workplace misconduct and you present evidence of your health problem having stabilized.
 
If you do end up being referred to the FTPC and having TLCs proposed by their prosecutor, this proposal will at least not have been influenced by for-profit interests.  
 3.) Monitoring responsibility.  
 
The CNO is a provincial regulatory body, not an all-inclusive monitoring program. Thus, although it has its own monitoring team, it outsources most monitoring responsibility to your own treating physician, including final decisions on many of your TCLs. So, for example, from a substance abuse perspective: the CNO may give your treating physician the responsibility of analyzing the results of your urine samples, the authority to determine the frequency at which you must attend peer support group meetings, the authority to determine whether you can work night or weekend shifts, and even the authority to determine the frequency you should submit to urine testing. This outsourcing works in your favour, because your treating physician has a fiduciary duty towards you, as is clearly stipulated by the College of Physicians and Surgeons of Ontario. This means your treating physician must make decisions that are in the best interest of you and your health; to do otherwise is medical malpractice. 
 
In contrast, the NHP is an all-inclusive monitoring program. It will primarily take on the responsibility for monitoring you, and will outsource little to your treating physician. You will be assigned a case manager as your primary contact point and compliance monitor, and final decisions on TCLs will be made by a director who is primarily guided by established NHP policy. The case manager and the director have responsibilities analogous to a parole officer and a judge, respectively. These two figures absolutely do not have a fiduciary duty towards you. Their duty is to the upholding of public safety.
 
_____________________________________________
 
There are, in my opinion, two primary advantages to the NHP route:
 
1.) Job application disclosure. 
 
Some nursing jobs, during the application process, will ask you if you have ever been investigated by the CNO for anything at all. This is typically phrased as some variation of the question: "have you ever been investigated by the CNO for professional misconduct, incompetence, or incapacity?" If you follow the NHP route, you can truthfully answer "no" to this question, as the CNO will not have initiated its health inquiry process against you. But if you follow the CNO route, you will have to answer "yes."  
 
Keep in mind that if a job application asks you if you have ever had a *finding* of incapacity – as opposed to have you ever been *investigated* for incapacity – you will almost certainly be able to truthfully answer "no" even if you follow the CNO route. This is because under the CNO route you will almost certainly enter into a voluntary undertaking without advancing to a formal hearing. If you enter into a voluntary undertaking, the incapacity investigation process is terminated before an official finding of incapacity is made. The FTPC only makes an official finding of incapacity if you escalate to a formal hearing and lose. 
 
Also keep in mind that it is possible for a job application to ask you whether you have ever enrolled in the NHP.
 
2.) Public register notation. 
 
The NHP route will not at any point lead to the posting of a notation under your name on the CNO's public register, while the CNO route will. As previously explained, the CNO's notation is temporary. It is also vague and not more than a few sentences long. If you end up agreeing to a voluntary undertaking, the notation is typically: "This member voluntarily entered into an undertaking agreeing to certain restrictions. The member shall not engage in the independent practice of nursing or through an agency. The member shall advise the member's employer(s) of the member's workplace restrictions." If one of your TCLs includes a controlled substance restriction, the notation will specifically state that, typically as: "The member shall advise the member's employer(s) of the member's workplace restrictions, one of which is no administration or access to controlled substances." 
 
This lack of notation is unlikely to be of much benefit for employment purposes, as the NHP requires you to disclose your workplace-related TCLs during interviews. It may, however, lead to less stigma from colleagues should they search you up on the public register.
 
In my opinion, these two advantages do not outweigh the detriments of enrolling in the NHP. 
 
I encourage you to contact the NHP yourself to ask questions. Do not use your real name, real phone number, or real email address. The information you provide is not confidential and, if they can trace it back to you, it may be reported to the CNO. Do not direct your questions to their administrative assistant; rather, ask their administrative assistant for one of their case managers to call you, as they can answer questions about the NHP in much more detail. By speaking to the NHP in an anonymous capacity, you can clearly explain your health situation and get a clearer picture of what you are likely to face from them. 
 
Given the NHP is a voluntary program, you may be considering the option of first enrolling in it to give it a try and with the understanding that, if you cannot tolerate it, you will withdraw from the program and follow the CNO route. 
 
This approach is technically open to you. I recommend against it, for the following reasons:
 
a.) The facts of your case may be such that if you choose the CNO route from the beginning, the ICRC may conclude the health inquiry process without taking any action. If you were to instead first choose the NHP route, you are almost certain to be sent for an IME and have TCLs applied to your license no matter the facts of your case (see: the NHP and for-profit interests). Once you withdraw from the NHP, your entire case file will be turned over to the ICRC. The information in this case file, which includes the IME report and what TCLs were applied to your license while you were enrolled, will heavily colour the ICRC's decision-making. Given the receipt of this information, the ICRC may refer you to the FTPC when they otherwise would not have.
 
If you end up being referred to the FTPC, the case file information will heavily colour the decision-making of the FTPC's prosecutor.
 
b.) Once you are on a route, momentum makes it difficult to switch. Whichever route you choose will be stressful. You will be loath to switch routes so as to minimize stress.
_____________________________________________
 
I hope the above advice is influential or at least provides informative context. 
 
I don't know what the original thought process was behind the creation of the NHP. Presumably it was benevolent. One of the four parties involved in its creation – the Ontario Nurses' Association – presents itself as an advocate for nurses. But, as it currently stands, the NHP is nothing more than a way to trick nurses into forfeiting the right to due process they are afforded by the Regulated Health Professions Act. It is a way to trick nurses into pleading guilty and receiving the maximum possible sentence.
 
Do not surrender your human rights on a silver platter. They should not be taken without a fight. Even if you have done something terribly wrong, this statement stands.
 
I recommend you to not enroll in the NHP.
 
Good luck.