Registed Nurses' Association of Ontario

Publications & Resources

NP Toolkit - Background & Introduction

Why is this Toolkit Needed

Amendments to Regulation 965 of the Public Hospitals Act, 1990 showcase Ontario as the first jurisdiction in Canada to legally authorize Nurse Practitioners (NPs) to admit, treat and discharge hospital in-patients. A two-stage process provided the legislated authority for NPs to discharge hospital in-patients effective July 1, 2011 while the authority for NPs to admit comes into effect July 1, 2012. These amendments were made to improve patient flow and system effectiveness in hospitals by providing equitable and timely access to care, particularly in underserviced, rural and remote populations. Reduced wait times, improved patient safety and quality of care, improved patient satisfaction and reduced costs are expected outcomes of these changes.

Given the significant challenges facing the health care system today, as well as the shift towards inter-professional care, it is untenable to limit the effective utilization of available healthcare professionals. Studies suggest adequate planning and stakeholder understanding are key to facilitating NP utilization in healthcare settings.1 Toolkits, such as this, enable successful implementation of NP utilization by providing NPs and hospital administrators with:

  • Key primary documents (e.g., relevant legislation and regulations),
  • Policy analysis (e.g., position statements by professional associations, prototype by-laws),
  • Practical tools for implementation and evaluation (collaborative practice agreements, slide deck presentations to hospital boards), and
  • Exemplars from hospital NPs and Chief Nursing Executives (CNEs) who have successfully implemented NP treat and discharge authority.
  • In addition, guiding documents from international jurisdictions, including New Zealand, Australia, the United Kingdom and the United States, have been included to broaden our perspective and consider innovative NP roles not yet conceived or enabled by legislation and regulation in Canada. Thus many tools are needed to effectively plan, implement and evaluate NP utilization in hospitals that ultimately improves hospital services through better access to care.

    How was the Toolkit Developed?

    In the spring of 2011, the Registered Nurses’ Association of Ontario (RNAO), in collaboration with its expert group the Nurse Practitioner’s Association of Ontario (NPAO), formed a task force co-chaired by Vanessa Burkoski, Chief Nurse Executive (CNE) at the London Health Sciences Centre, and Michelle Acorn, President of NPAO. The task force engages CNEs and NPs from rural and urban community hospitals across Ontario, to facilitate adoption of regulation 965 amendments and advance the full utilization of NPs in Ontario’s hospitals. RNAO also invited OHA to join, which at the time decided to first confer with their members before sharing efforts. The Nurse Practitioner Utilization in Hospitals Toolkit was launched February 13, 2012 and published online, based on the current state of knowledge with the intent to remain evergreen and responsive to further legislative and regulatory changes.

    Who are the Potential Users of the Toolkit?

    • This Toolkit has been developed to help a wide range of organizations and healthcare teams to implement the NP role in hospital inpatient settings.
    • Toolkit users may include nurse practitioners, hospital administrators, inter-professional care providers, nursing leaders and healthcare managers, government policy makers, healthcare planners, NP educators and researchers.

    How will this Toolkit Help?

    Users of this Toolkit may:

    • Determine the impact of introducing NPs utilization in Ontario hospitals
    • Consider their response to significant questions before implementing NPs in hospitals
    • Identify the legal and regulatory issues involved with NP Utilization in Ontario hospitals
    • Create customized bylaws, collective practice agreements and presentations using the templates provided
    • Establish a plan to clearly identify and communicate NP roles and responsibilities in the hospital setting
    • Create a sustainable budget to implement NPs in the hospital setting.
    • Design a method to evaluate the impact of NPs on outcomes including quality and safety improvement, patient satisfaction, patient flow, value and organizational effectiveness
    • Consider innovative roles for NPs, once enabled by legislative and regulatory changes
    • Have input into future revisions of this toolkit but providing continuous feedback on the documents selected and recommendations for additional documents that should be added

    Strategies for Getting the Most out of this Toolkit2

    • Keep in mind that this toolkit should be used as a flexible healthcare planning guide. The use of steps, activities and tools is not meant to be prescriptive. Each organization or healthcare planning team can select and/or adapt the specific activities and tools to best fit their circumstances.
      You can use the toolkit by moving sequentially through each chapter or start with the chapter that best fits the context of your healthcare planning situation. Healthcare planning is not a linear process and each chapter is not a discrete step. You may find it necessary to revisit earlier chapters from time to time as you move through various chapters.
    • You may not need to use each tool as you may have some work already completed. For example, your organization may have already considered the questions in the discharge elements document, as part of their strategic planning process.
    • There are numerous tools and checklists that you can use throughout the toolkit. You will be guided to different parts of the toolkit when appropriate.


    1 DiCenso, A., Bryant-Lukosius, D., I. Bourgeault et al. (2009). Clinical nurse specialists and nurse practioners in Canada: A decision support synthesis.Ottawa, ON: Canadian Health Services Research Foundation (
    2 Adapted from Cancer Care Ontario (2011). APN Roles in Cancer Control Toolkit. Retrieved January 12, 2012 at