In April 2011, the Ontario government proposed legislative amendments intended to expand the role of nurse practitioners (“NPs”) in Ontario hospitals. On July 1, 2011, key provisions which permit NPs to discharge patients, treat hospital in-patients, order laboratory tests within their full scope of practice and complete death certificates came into force.
These amendments facilitate broad changes to NPs’ hospital role and have significant implications for the provision of patient care which need to be carefully considered by hospitals.
In recent years, registered nurses in the extended class, commonly referred to as nurse practitioners or NPs, have seen their scope of practice and professional responsibilities expanded. Many hospitals in Ontario currently employ and/or have granted professional staff privileges to NPs, enabling them to provide care to hospital patients.
However, pursuant to Regulation 965 to the Public Hospitals Act (the “General Regulation”), NPs were only permitted to independently register, diagnose, prescribe for and treat out-patients of a hospital. NPs were not permitted to independently admit individuals as in-patients or to discharge patients from the hospital – this authority was restricted to physicians, dentists and midwives who are members of hospital staff. Care or discharge of in-patients by a NP could only occur through delegation (e.g. medical directive), under the authority of a physician.
Ontario Regulation 216/11 (“the Amendment”) amends the General Regulation, to enable NPs who hold privileges or who are employed by a hospital to independently:
- Admit patients to the hospital;
- Attend hospital in-patients;
- Discharge hospital patients; and
- In certain circumstances, complete a medical certificate of death for a patient who dies in the hospital.
Incidental to these changes, provisions in the General Regulation regarding responsibilities of the Medical Advisory Committee (section 7), notification of dangerous or infectious patients (section 14), completion and authentication of medical records (section 19), admitting notes (section 25), and the definitions for “attending registered nurse in the extended class” and “extended class nursing staff” (section 1) have been amended to reflect the broader role NPs may have in a hospital.
Amendments have also been made to the Laboratory and Specimen Collection Centre Licensing Act and Regulation 662 to the Health Insurance Act. These amendments broaden the authority of NPs to order laboratory tests by removing schedules which previously restricted the tests NPs may order, and make laboratory tests ordered by NPs for out-patients and in-patients an insured hospital laboratory service.
Coming into Force
The amendments take effect in two stages. On July 1, 2011, NPs were given the authority to discharge and attend in-patients, complete death certificates, and order any lab test that falls within their professional scope of practice and competencies.
One year later, on July 1, 2012, NPs will be permitted to admit patients to hospital.
Implications for Hospitals
While the amendments expand the role and responsibilities NPs are permitted to have in a hospital setting, it is up to each hospital to determine the specific authorities it will grant to the NPs who provide care to its patients. In other words, each hospital is responsible for deciding whether it will permit some or all of its NPs to admit or discharge patients, attend hospital in-patients, order laboratory tests and/or complete death certificates.
Introducing such changes in a hospital can have significant implications for the delivery of hospital care. An expanded NP role could have a positive impact on patient flow, improve efficiencies in care and result in better patient outcomes; however it is important for hospitals to understand that the effects of these broader authorities may be far-reaching. For example, permitting NPs greater authority to order laboratory tests and/or to admit in-patients can have considerable consequences for the allocation and utilization of scarce hospital resources. It is incumbent on hospitals to ensure that any changes to NP roles and responsibilities do not risk compromising quality patient care.
Before making any changes, a hospital should give full consideration to the role(s) of NPs within the hospital and the relationships the hospital wishes to establish in this respect, including but not limited to:
- scope of practice and competencies of current NP staff in the context of existing job descriptions, organizational structures, and patient care models;
- implications of expanded NP roles and responsibilities on resource allocation and utilization;
- whether hospital privileges should be extended to NPs in an expanded role, including whether NPs should be granted the authority to admit and/or discharge patients;
- the role and responsibilities of the Medical Advisory Committee (“MAC”) regarding privileges to be granted to NPs and ensuring quality of NP care;
- whether NPs will be recognized as the most responsible provider for patients who are admitted by a NP or whom a NP attends as an in-patient;
- whether NPs will be granted expanded authority to order laboratory tests and/or to access other hospital resources (e.g. make referrals to specialists);
- delegation of controlled acts and orders, including whether NPs will have authority to delegate to other health professionals (e.g. pursuant to a medical directive); and
- whether the hospital’s insurance coverage extends to NPs in an expanded role, and whether NPs should be required to obtain their own extended insurance.
It will also be necessary for hospitals to make the requisite changes to current by-laws, professional staff rules and regulations, policies, and medical directives, as applicable, to ensure they reflect any expanded roles and responsibilities for NPs. For hospitals who currently employ NPs, consideration should be given as to whether employment contracts, collective agreements and other documents governing these relationships require review and/or amendment.
Please contact our Health Industry Group to discuss the impact of these amendments, or for assistance in reviewing current NP structures and implementing an expanded NP role in your hospital.
 Of note, a NP’s authority to complete a medical certificate of death under the Vital Statistics Act in a hospital remains subject to the restrictions under the Act for NPs – i.e. a NP may complete the medical certificate of death if the NP had primary responsibility for the care of the deceased during his/her last illness; and during that last illness: death was expected, there was a documented medical diagnosis of a terminal illness made by a qualified medical practitioner, there was a predictable pattern of decline, and there were no unexpected events or unexpected complications.
Joshua and Jesstina would like to thank Pietro Palleschi, 2011 Summer Student with Miller Thomson LLP, for his assistance in preparing this Communiqué.