Registed Nurses' Association of Ontario

Bill 171: Health System Improvements Act

Bill 171: Health System Improvements Act

The Registered Nurses’ Association of Ontario (RNAO) is the professional organization for registered nurses who practice in all roles and sectors across Ontario. Our mandate is to advocate for healthy public policy and for the role of nursing in shaping and delivering health services. RNAO is pleased to provide this submission on Bill 171, An Act to improve health systems by amending or repealing various enactments and enacting certain Acts, 2006, to the Standing Committee on Social Policy.

We will limit our submission to Schedules B, F, K, M, and Q of the Bill.

Schedule B: Amendments Concerning Health Professions, Section 14

While we welcome the title protection for nurse practitioners (NPs) provided in section 14(1)(1), the proposed changes to the Nursing Act fall far short of the proposed changes to the Nursing Act, the Extended Certificate of Registration regulation, and the Controlled Acts regulation proposed by the College of Nurses of Ontario (CNO), the regulatory body for nursing in Ontario. We urge the government to act immediately on the advice of CNO and enact the changes that are essential to improving client care, enhancing access to health services, and providing further protection to the public.

Bill 171 does not further the implementation of CNO’s proposed changes to the RN Extended Class (RN(EC)) registration, which would regulate nurse practitioners holding specialty certificates in primary health care, paediatrics, adult, and anaesthesia.

The changes proposed by CNO would incorporate Acute Care Nurse Practitioners into the Extended Class and enable all RN(EC)s to function autonomously without medical directives or delegation, sharpening lines of accountability. The proposed changes would allow RN(EC)s to use their knowledge, skills, and experience to a greater extent, and to practice to their full scope to better serve the needs of Ontarians.

The proposed change to the Nursing Act in Bill 171 with respect to prescriptive authority falls far short of open prescribing. It proposes moving the process from a drug-specific list to one of categories of drugs. In the end, this may prove to be more time consuming and challenging to implement than the current model.

CNO proposes open prescribing for RN(EC)s. In a context of rapid technological change and evolving roles, there is compelling evidence that the current list-based approval process for RN(EC) diagnostic and prescriptive authority is untenable. The current list-based system results in treatment delays, unnecessary duplication, and misallocation of resources. Open prescribing for diagnostic tests and pharmaceuticals already exist in several Canadians jurisdictions, including Saskatchewan, Manitoba and British Columbia. As of 2000 in the United States, there were 25 states that gave full prescriptive authority to nurse practitioners, including for controlled substances.

We recommend that the CNO legislative amendments, which appear as Appendix 1, be incorporated into this Bill.

RNAO has also proposed the following expansion of all RNs’ scope of practice:

1. Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the diagnosis;
2. Setting or casting a fracture of a bone or a dislocation of a joint;
3. Applying a form of energy prescribed by the regulations under this Act (i.e. RHPA); and,
4. Dispensing a drug as defined in subsection 117 (1) of the Drug and Pharmacies Regulation Act. R

Ns should have the authority to perform these acts within nursing scope of practice based on knowledge, skill, and experience. This will ensure timely access to care; reduce the need for delegation; and, support progression of care management in a timely way.

Schedule F: Health Protection and Promotion Act

We welcome the amendments to Sections 1, 26, 30, 34, 37, and 38 that incorporate RN(EC)s into the Act.

However, we urge the government to heed the recommendation of the Campbell Report to incorporate the precautionary principle into the Act. We would recommend that the precautionary principle be incorporated in the duties of Boards of Health into Part II, Section 4 of the Act.

Schedule K: Ontario Agency for Health Protection and Promotion Act, 2006

RNAO continues to support the establishment of the Ontario Agency for Health Protection and Promotion, and welcomes this legislation as the next step in this process. We have the following suggested amendments to the Bill, which will strengthen the legislation.

As “health disparities are the number one health problem in the country,” it is essential that the purpose of this Act should include reducing health inequities by addressing the social determinants of health across sectors.

We recommend that that the purpose of the Act be amended in the following manner, with the additions in italics.

The purpose of this Act is to enhance the protection and promotion of the health of Ontarians and reduce health inequities through the establishment of an agency to provide scientific and technical advice and support to those working across sectors to protect and improve the health of Ontarians and to carry out and support activities such as population health assessment, public health research, surveillance, epidemiology, planning, and evaluation.

In keeping with previous submissions on the necessity of integrating the social and economic determinants of health into the Ontario public health mandate and specifically into the mission of the Ontario Agency for Health Protection and Promotion, RNAO suggests the following revisions to the objects which are italicized:

6 (a) to provide scientific and technical advice and support to the health care system and the Government of Ontario in order to protect and promote the health of Ontarians and reduce health inequities;
(b) to develop, disseminate and advance public health knowledge, best practices, and research in the areas of population health assessment, infectious diseases, health promotion, chronic diseases, injury prevention, and environmental health;
(c) to inform and contribute to policy development processes of the health care system and across sectors within the Government of Ontario through the provision of advice and impact analysis of public health issues;
(d) to develop, collect, use, analyse and disclose data, including population health, surveillance and epidemiological data, across sectors, including human health, environmental, animal and agricultural sectors, education, community and social services, criminal justice, housing, and employment, in a manner that informs and enhances healthy public policy and public health planning, evaluation and action;
(e) to undertake, promote and co-ordinate public health research in co-operation with academic and research experts as well as the community;
(f) to provide education and professional development for public health professionals, scientists, researchers, and policymakers across sectors; ….

Schedule M: Regulated Health Professions Act

We have the following concerns about the changes to this Act.

We are concerned that the proposed changes to RHPA section 23 (2) 6 would result in personal health information of health providers becoming publicly available. As a result, we would recommend that this clause revert to the wording in the current legislation and read:
(6) the result of every disciplinary and incapacity proceeding;

We are also concerned about the expansion of mandatory reporting by a facility operator of sexual abuse by a health professional to include incapacity or incompetence. We caution that mandatory reporting of incapacity would reduce the likelihood that health professionals would disclose incapacity issues to their employers and would therefore reduce access to assistance through such resources as Employee Assistance plans. We therefore recommend that incapacity be removed from the proposed amendment to Section 85.2 of the RHPA.

Schedule Q: Psychotherapy Act

RNAO supports the establishment of this Act and the public protection that it provides. However, we would ask for an amendment to the proposed Section 8(1) so that other professionals who have access to the Psychotherapy Act, including physicians, occupational therapists and social workers, can use the title psychotherapist or registered mental health therapist.


(For references, please download the file below [PDF - 68 KB])

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