Policy and Political Action

Policy & Political Action

RNAO & ONA joint letter Re: expanding RPN scope of practice

September 16, 2020

Sandra Robinson, Council President 
Anne Coghlan, Executive Director and Chief Executive Officer 
College of Nurses of Ontario 
101 Davenport Road 
Toronto, ON M5R 3P1 

Dear Sandra and Anne, 

Re: Expanding RPN scope of practice 

The Registered Nurses’ Association of Ontario (RNAO) and the Ontario Nurses’ Association (ONA), out of grave concern for public safety and in the best interests of Ontarians, are urging CNO in the strongest possible terms to table – immediately – any further discussions on the proposed regulation for registered practical nurse (RPN) scope of practice expansion. Our recommendation is to delay these discussions until post-COVID, and with due processes in place. 

In September 2020, CNO shared its decision to postpone the rollout of its new Quality Assurance (QA) program until 2021 and instead, simplify and streamline the existing QA program due to the COVID-19 pandemic.  RNAO and ONA agree with that decision and urge CNO to apply the same considerations to the proposed RPN scope of practice expansion during this time, given the “pandemic has profoundly impacted the nursing profession in many ways.”  A nursing practice change that has far-reaching implications on patient safety, nursing practice and the health system should equally take into account the same unprecedented circumstances.

To our alarm, the expansion of RPN scope of practice would include independent initiation of four controlled acts that are currently reserved for the registered nurse (RN) scope of practice. Reiterating the strong opposition to this regulatory change expressed by each of our organizations individually, RNAO and ONA are collectively taking a stand against any further action by CNO to move forward with proposed regulation. The rationale for our action is clearly laid out in our respective letters to CNO. Both were included in the June 2020 Council Briefing Package.  

RNAO and ONA were both in attendance at the CNO Council meeting on June 3, 2020. We are taking this opportunity to, once again, sound the alarm on RPN scope expansion that will render the RPN and RN scope virtually identical, despite the vast differences in academic preparation. 

CNO’s three-factor framework practice guideline clearly states: “Enhanced competence through continuing education and experience does not mean that an RPN will acquire the same foundational competencies as an RN.” It also states: “This will only occur through the formal education and credentialing process.”  

To practice in Ontario, RNs must have a baccalaureate degree – either obtained through a four-year university nursing program or collaborative college-university nursing program with greater breadth and depth of education; whereas, RPNs must have a diploma in practical nursing by taking a two-year college program.  

Our shared and objective observations from the discussions that took place amongst CNO Council members on June 3 have left us with grave concerns in terms of public safety, the need for a sound academic base to support scope of practice, and the role of a nursing regulatory body. Some of these observations are:

  1. A stark lack of evidence referenced to support the proposed changes to RPN scope of practice. Material presented to CNO Council at meetings, including a synthesis of literature and a jurisdictional review , in June 2018, September 2019 and December 2019, make it clear that the expanded scope of RPN practice is not supported by robust evidence or a clear public need to increase Ontarians access to care. Further, the evidence does not demonstrate or support that it is in the best interests of Ontarians’ health outcomes to expand the scope of RPN practice. The position of other Canadian jurisdictions echoes our views. For example, in British Columbia, licensed practical nurses (LPN) require an order to carry out certain restricted activities, comparable to the above-mentioned controlled acts in Ontario, to support what their regulatory body deems to be safe, competent and ethical care. 
  2. The inability of CNO Council members to differentiate between “performing” a controlled act and “initiating” a controlled act – and staff’s failure to prepare council with the necessary information to understand this difference. There were various comments made that the proposed regulation to initiate is not that much of a change since RPNs already “perform” many of the skills outlined in the scope changes. It is critical to note that initiating requires entirely different skill sets than performing. Initiation of acts requires a broader and deeper knowledge base, an ability to think critically, and the capacity to make sound and evidence-informed judgments. These are all part of the baccalaureate education base for RNs. Initiation of acts – such as advanced wound care (i.e., debridement), venipuncture, and putting an instrument/hand/ finger beyond the two cavities when assisting/assessing with health management activities – also implies a sense of urgency and a complex patient situation. Such flippant commentaries obfuscating “initiation of acts” versus “performance of acts” demonstrate that staff has not prepared the CNO Council with the necessary knowledge to have well-informed discussion and decisions. It also calls into question CNO Council’s application of the three-factor framework. 
  3. CNO Council’s apparent position regarding the RPN self-identifying as competent to perform the expanded scope of practice, and the employer’s responsibility to provide the required education to RPNs to enable initiation of such acts. The fact that CNO will not assist with establishing educational standards or practice-related competencies for this scope change is shocking considering CNO’s regulatory oversight includes a responsibility to establish competencies, approve education, set and enforce standards, provide practice support, and administer a QA Program. Conversely, all of these regulatory oversight activities appear to be scrutinized at length in comparison to RN prescribing, which is greatly delayed, exists in many other international and Canadian jurisdictions, and is compromising the public’s access to health services.  RNAO and ONA are adamant that leaving the responsibility to RPNs to self-identify competence and to employers to provide the required education to initiate these acts will compromise public safety. It also begs the question of whether a nursing regulatory body is needed if this is considered acceptable. 
  4. CNO Council’s failure to formally review the public consultation results. The public consultation reflects a critical component of stakeholder engagement in all regulatory changes, and provides a barometer of both the need for and appropriateness of regulatory changes. At its meeting on June, 2020, CNO Council did not review the consultation results, which indicate that the majority (56.7 per cent) of respondents, which includes NPs, RNs, RPNs, public members and others, do not support or are unsure about the regulation change. Among public respondents, an astounding 86 per cent did not support the change.  We express grave concern regarding the downplaying of these critical results. 

In addition to the above, RNAO and ONA find it unacceptable that CNO proceeded with public consultations from March to May 2020. This was during the height of the COVID-19 pandemic, when key stakeholders – RNs, RPNs and nurse practitioners (NP) – were working tirelessly to protect the health and safety of our communities. So too were their associations – RNAO and ONA.

In summary, we strongly oppose the proposed RPN scope of practice change. With this letter, we urge CNO Council – at its next meeting Sept, 17, 2020 – to table the item on RPN scope of practice expansion until post-COVID, when proper CNO Council education and review of the consultation survey feedback can take place at an open CNO Council meeting. We also expect proper consultation with stakeholders. It is our view – and the view of most respondents to your consultation survey – that the proposed regulatory changes are neither necessary nor urgent. RNAO and ONA reiterate – in the strongest possible terms – to the CNO Council and to Health Minister Christine Elliott that the proposed regulation for RPN scope of practice expansion is not appropriate based on the evidence. It is also not in the best interests of public safety for Ontarians. 

RNAO and ONA are unwavering in our commitment and number-one priority: the safety of Ontarians who entrust our profession to provide quality, safe nursing care that is informed by robust evidence and best practice

With kind regards,

Doris Grinspun, RN, MSN, PhD, LLD(hon), Dr(hc), FAAN, O.ONT.
Chief Executive Officer, RNAO

Morgan Hoffarth, RN, MScN
President, RNAO

Beverly Mathers, RN, BA, MA
Chief Executive Officer, ONA

Vicki McKenna, RN
President, ONA


CC: CNO Council 
Premier Doug Ford
Hon. Christine Elliott, Minister of Health 
Helen Angus, Deputy Minister of Health 
Hon. Merrilee Fullerton, Minister of Long-Term Care 
Richard Steele, Deputy Minister of Long-Term Care
Matthew Anderson, President & Chief Executive Officer, Ontario Health 

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