Hon. David Caplan
Ministry of Health and Long-Term Care
56 Wellesley Street West, 12th Floor
Toronto ON M5S 2S3
January 29, 2009
Dear Mr. Caplan,
Thank you for the opportunity to respond to the March 2008 Report to the Minister of Health and Long-Term Care on the Review of the Scope of Practice for Registered Nurses in the Extended Class (Nurse Practitioners). These recommendations would have the needed effect of strengthening Nurse Practitioner (NP) practice across the province, and supporting implementation of Nurse Practitioners in a wide variety of settings in the health care system.
RNAO endorses, in the strongest possible terms, regulatory and legislative changes that will facilitate implementation of the recommendations in this report[i] which urges maximizing the scope of practice, and allowing Nurse Practitioners (NPs) to use their knowledge, skills, and experience to the maximum extent to best serve the needs of Ontarians.
As the professional organization for Registered Nurses in the province, the RNAO firmly believes these changes will serve the public interest by responding to demands for increased patient access to appropriate care, improving continuity of care, providing access to essential health services in the most cost-effective manner, and assuring full accountability through greater clarity in the roles of those professionals working collaboratively in Ontario’s health care system.
Regulation, Certification and Title Protection
Re: Recommendations 1-3, and 5-7
The proposed changes reflect current education, competencies, and everyday practice of Nurse Practitioners; increase client access to timely and essential health-care services; increase efficiencies within the system, enhance cost-effectiveness by decreasing duplication; and, clarify and enhance Nurse Practitioner accountability. These changes will result in improved retention and recruitment of Nurse Practitioners working in Ontario by enabling them to be utilized to their full capacity, and will thus aid in ameliorating many of the current health system challenges.
Under the current legislative framework, NP practice is limited by the requirement for delegation to perform several controlled acts: setting or casting a fracture or a dislocation; dispensing, selling or compounding a drug, and applying forms of energy. Over time, because of technological and scientific advancements, changing practice realities, and evolving population health needs, these acts have become incorporated into the day-to-day practice of Nurse Practitioners. Today, patients’ health and safety are compromised due to access and treatment delays; there are system inefficiencies and a great deal of frustration amongst NPs who feel their education and competencies are not fully utilized.
§ RNAO strongly supports the recommendations regarding standardization and revision of noted regulations for the purposes of clarity.
§ RNAO encourages the standardization of terminology in all regulations, promoting the term “Nurse Practitioner” in place of “Registered Nurse in the Extended Class” (and the like), as well as the abbreviation “NP” in place of “RN(EC)”. Current terminology is inconsistent, and the use of uniform language would serve to prevent public confusion.
§ RNAO endorses expanded access to controlled acts NPs are authorized to perform, including setting or casting a fracture or a dislocation; open prescribing and dispensing, selling or compounding a drug, and applying forms of energy.[ii] In a context of rapid technological change and evolving roles, there is compelling evidence that the current list-based approval process for Nurse Practitioner diagnostic and prescriptive authority is untenable and that its inadequacy compromises patient access and safety. Open prescribing for diagnostic tests and pharmaceuticals is vital to meet clients’ needs. The current list-based system results in delays in treatment, unnecessary duplication and misallocation of resources.
The NP-Anaesthesia role is well established in other jurisdictions, and has already been adopted by government as part of an overall strategy to improve access to surgical procedures, decrease surgical shortages and improve pain management. In addition, the education program currently underway at the University of Toronto projects the graduation of 4 students in 2009. RNAO encourages the swift implementation of the acute-care specialty “Anaesthesia” (NP-Anaesthesia), and encourages extending title protection to this and all acute care specialties recommended by the College of Nurses of Ontario (CNO).
Standards, Limitations, Conditions and Registration Requirements
Re: Recommendations 4-5, 8-12, and 16-19
The proposed legislative and regulatory amendments will advance timely access by enabling NPs to directly provide needed health services within their legal scope of practice, the practitioner’s individual level of competence and in accordance with best practices and the regulatory standards set by CNO. Medical directives or delegation in both in-patient and out-patient settings, is an outdated and inefficient practice that blurs and confuses, rather than delineates and clarify, lines of accountability for health professionals and for the public.
§ RNAO supports the requirement for NPs, as with every College member, to comply with all standards, limitations and conditions established by the College of Nurses of Ontario for the performance of controlled acts, and that an interprofessional committee be involved in the development of these standards, limitations and conditions.
§ However, RNAO feels that since core competencies, registration requirements and continuing competency expectations are well established in the self-regulation framework, restricting nurse practitioners’ practice to an acute or primary speciality is unnecessary. In addition, the requirement of a one-year, formal supervised practice by either a NP or physician post-certification is unreasonable.
Quality Assurance and Continuing Competence
Re: Recommendations 13-14
RNAO fully supports CNO’s proposal to place conditions necessary to protect the public in practice standards rather than in legislation. Monitoring through a regulatory body rather than through legislation is consistent with self-regulation, and the most appropriate and accessible way to secure competency.
§ RNAO endorses the development of a new and enhanced CNO Quality Assurance program, along with the amendment to the General Regulation clause ensuring that members conduct their practices consistent with the requirements of the Nursing Act.
Mandatory Professional Liability Protection.
Re: Recommendation 15
Registered Nurses, including Nurse Practitioners, are eligible for professional liability protection through membership in RNAO which is a member organization of the Canadian Nurses Protective Society (CNPS).
As a result of discussions involving RNAO, NPAO, the Nursing Secretariat and the Canadian Nurses Protective Society (CNPS), enhancements were made to CNPS protection for NPs across Canada in 2004. The following year, CNPS and the Canadian Medical Protective Association (CMPA) issued a joint statement on liability protection for NPs and family physicians in collaborative practice.[iii]
§ RNAO recommends mandatory professional liability protection for all nurses who work in Ontario as a measure to protect themselves and the public. Unlike other provinces, in Ontario, professional liability protection is not mandated by the regulatory body.
§ RNAO is the professional association representing Registered Nurses, including Nurse Practitioners, who practice in all roles and sectors across Ontario. All RNAO members who are currently registered in good standing with the College of Nurses of Ontario (CNO) are automatically eligible for assistance for liability and malpractice protection from the Canadian Nurses’ Protective Society (CNPS).[iv]
§ For Nurse Practitioners, CNPS protection is available up to $5,000,000 for each occurrence to a maximum of $5,000,000 per year for civil lawsuits, successfully defended criminal charges and alleged breaches of statute (other than professional discipline or labour relations) arising from the provision of professional nursing services.
The majority of NPs in Ontario are employees, and, as employees, are generally covered by the legal principle of vicarious liability. Vicarious liability means that “if an employee is found liable in a civil lawsuit, the employer is generally ordered by the court to pay the monetary amounts called damages,” and to cover legal costs. Thus, although it is unlikely that NPs who are employees need additional individual insurance, RNAO strongly believes it is in the public interest for all nurses, including all NPs, to have liability insurance adequate to the risks presented by their practice.
Re: Recommendation 19
RNAO fully supports the proposed amendments to the following legislation:
§ Public Hospitals Act, 1990 – Regulation 965 and Health Insurance Act, 1990 – Regulation 552: Authorization to admit and care for inpatients
§ Healing Arts Radiation Protection Act, 1990: Authority to order x-rays
RNAO further asks HPRAC to consider the following amendments to legislation:
§ Highway Traffic Act, 1990 – Regulation 203: Authorization to assess for fitness to drive.
§ Ontario Drug Benefit Act, 1990: payment for individual claim review
§ Patients Restraints Minimization act, 2001 c.16, s.10 (1): authority to order patient restraints
§ Mental Health Act, 1990: Authority to order a Form 1
§ Health Insurance Act, Regulation 552: enabling the referral to specialists.
We commend and thank HPRAC for its important work and ongoing efforts to engage the public in broad and comprehensive consultation on the Scope of Practice of Registered Nurses in the Extended Class (Nurse Practitioners). HPRAC’s recommendations will strengthen Nurse Practitioner (NP) practice in all sectors across the province, and contribute greatly to a more effective health system. RNAO supports HPRAC’s recommendations, in the strongest possible terms, knowing that their implementation will serve well the public interest by increasing access to appropriate care, improving continuity of care, providing access to essential health services in the most cost-effective manner, and assuring greater clarity in the roles of those professionals working collaboratively in Ontario’s health care system.
With regards and utmost respect,
Wendy Fucile, RN, BScN, MPA, CHE
Registered Nurses’ Association of Ontario
Doris Grinspun RN, MSN, PhD (cand), O.ONT.
Registered Nurses’ Association of Ontario