Registed Nurses' Association of Ontario


Mind the safety gap in health system transformation: RNAO issues recommendations to ensure patients come first


TORONTO, May 9, 2016 – The top professional nursing organization in Ontario says reforms expected in the coming weeks to radically change the way health services are delivered in the province won’t succeed unless they include a comprehensive health human resources (HHR) strategy.

Representatives of the Registered Nurses' Association of Ontario (RNAO), the province’s leading authority on nursing and health policy, released a report Monday at Queen’s Park outlining what must happen if Health Minister Eric Hoskins wants to achieve his goal of putting patients first – an initiative RNAO supports.

Mind the safety gap in health system transformation: Reclaiming the role of the RN takes an extensive look at recent trends in nursing employment and sheds light on how the minister’s priorities to improve the system are completely at odds with the reality of how nursing human resources are deployed today.

RNAO says developing a comprehensive and well-thought out interprofessional HHR plan is a must for any major health system transformation, which is why it is the report's first recommendation. "Given that nurses make up the largest share of regulated health professionals in the province, we are advancing the HHR agenda by issuing this report," says RNAO's newly installed president, Carol Timmings, adding that "nurses play a central role in delivering health services, and statistical trends in nursing skill mix and organizational models of care delivery don't bode well for patient safety and health outcomes."

"How can we drive the important changes outlined in the health minister’s Patients First report without the fuel to make these changes happen?" asks Timmings. "It makes no sense that at a time when patient acuity is increasing in hospitals and in the community sector, RNs are being replaced by less qualified personnel."

RNAO is urging the minister of health and the Local Health Integration Networks (LHIN) to issue an immediate moratorium on the replacement of RNs, a trend associated with increased morbidity and mortality. “RNs are being replaced simply to cut costs, but this practice flies in the face of well-documented evidence that shows employing more RNs actually costs less. This is because a higher proportion of RNs results in lower complication rates, and fewer hospital re-admissions,” says Timmings. And yet, data shows that between 2005 and 2010, the ratio of RNs to diploma-prepared registered practical nurses (RPN) was 3:1. By 2015, the ratio had shockingly dropped to 2.28:1. Ontario has the second-worst RN-to-population ratio in Canada.

RNAO CEO Doris Grinspun says "these statistics must trigger alarm bells, because if the government's goal is to shorten lengths of stay in hospital and re-orient the system towards greater community care, a large influx of RNs is needed to respond to rising acuity levels, especially those of hospital patients deemed the sickest of the sick." That's why RNAO is calling on the ministry to mandate an all-RN nursing workforce in acute care, teaching, and cancer care hospitals within two years, and in large community hospitals within five years.

Given that acuity will continue to increase in home care and long-term care, the report also includes recommendations for these sectors. For example, RNAO welcomes the health minister's promise to move more care into the community. But as patients are discharged from hospital earlier and with more complex care needs, the report recommends every first home care visit be conducted by an RN.

The association says the minister's vision of a more person- and family-centred system also needs to take full advantage of the expertise and legislative authority of nurse practitioners (NP). To that end, RNAO's report includes specific recommendation aimed at removing all barriers that handcuff their ability to fully care for Ontarians, including those who reside in long-term care homes.

Changes in nursing skills mix aren't the only concern highlighted in RNAO's report. The way nurses are increasingly being forced to deliver care is another troubling trend. Grinspun says more and more hospitals are resorting to functional or team-based organizational models of nursing care delivery that result in fragmented care where no one is in charge of the comprehensive care needs of the patient. These models, in which patient care is broken down into a series of tasks that are delegated to various members of the nursing team, have huge implications in terms of quality of care and safety, says Grinspun. "Imagine being a patient or family member and not knowing who your nurse is?"

She says some hospitals are relying on these models to meet bottom line pressures. "Not only are they ineffective, there is no continuity of care. They are the furthest thing from putting the patient first," says Grinspun. RNAO's report recommends that hospitals use primary nursing as the most effective model, where one nurse is in charge and takes full responsibility for planning and delivering all of the care needs of a patient throughout their stay.

The report makes eight recommendations:

  • MOHLTC develop a provincial evidence-based interprofessional HHR plan to align population health needs and the full and expanded scopes of practice of all regulated health professions with system priorities
  • MOHLTC and Local Health Integration Networks (LHIN) issue a moratorium on nursing skill mix changes until a comprehensive interprofessional HHR plan is completed
  • Mandate LHINs to use organizational models of nursing care delivery that advance care continuity and avoid fragmented care
  • MOHLTC legislate an all-RN nursing workforce in acute care within two years for tertiary, quaternary and cancer centres (Group A and D hospitals) and within five years for large community hospitals (Group B)
  • LHINs to require that all first home health-care visits be completed by an RN
  • MOHLTC, LHINs and employers eliminate all barriers, and enable NPs to practise to full scope, including: prescribing controlled substances; acting as most responsible provider (MPP) in all sectors; implementing their legislated authority to admit, treat, transfer and discharge hospital in-patients; and utilizing fully the NP-anaesthesia role inclusive of intra-operative care
  • MOHLTC legislate minimum staffing standards in LTC homes: one attending NP per 120 residents, 20 per cent RNs, 25 per cent RPNs and 55 per cent personal support workers
  • LHINs locate the 3,500 CCAC care co-ordinators within primary care to provide health system care co-ordination and navigation, which are core functions of interprofessional primary care

Grinspun says RNAO applauds Minister Hoskins for his desire to revamp the health system. "If we are going to shake up the system, we must make sure that it’s set up to succeed," adding the most important element in the delivery of health services is front line staff. "Those who provide care day-in and day-out are the ones who will help us deliver the necessary changes Ontarians have been waiting for, and we will do our part to ensure their experiences and health outcomes are the best."

RNAO is the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario. Since 1925, RNAO has advocated for healthy public policy, promoted excellence in nursing practice, increased nurses’ contribution to shaping the health-care system, and influenced decisions that affect nurses and the public they serve. For more information about RNAO, visit or follow us on Facebook and Twitter.

Download a copy of the report at

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To arrange an interview with an RN or NP, please contact:

Marion Zych
Director of Communications
Registered Nurses’ Association of Ontario (RNAO)
647-406-5605 (cellular)
416-408-5605 (office)