After years of advocacy from RPNAO, we’re thrilled that the Ministry of Health has listened to the feedback from Registered Practical Nurses (RPNs) and directed the College of Nurses to move forward with important changes to RPN scope of practice by June 2020. Since we announced this exciting news, many of our members have asked questions about what the changes will look like and what it will mean for their practice. To help answer those questions, we've developed this Q&A:
How has RPN education changed since the 1991 Nursing Act was enacted?
Registered Practical Nurses (RPN) are knowledge-based health professionals. When the current regulations governing RPN scope of practice were put in place in the Nursing Act 1991, RPN education looked very different from today. Over the past several decades, Ontario PN programs have expanded from one-year certificates to two or two and a half year diplomas with RPNs graduating with a robust body of nursing knowledge. Previously, things like wound care or IV initiation were not part of the curriculum. These acts have now become integral to RPN education and a regular part of practice for many RPNs across the province. Additionally, many RPNs choose to acquire supplemental specialized training in certain practice areas such as wound care that further expand their nursing knowledge and ability to deliver excellent care.
How will these changes impact RPN practice and workload?
The changes to scope of practice will authorize qualified RPNs to initiate acts that they already performed on a regular basis. Currently, an order is necessary to allow RPNs with the appropriate knowledge, skill and judgment to perform these procedures and in accordance with the College of Nurses of Ontario (CNO) practice standards. RPNs are accountable to assess the appropriateness of the intervention for a particular patient and for their particular situation even with the order. In many cases, especially in remote and rural communities, prescribers such as MDs, NPs and RNs rely on the RPNs’ knowledge, skill and judgement to determine whether an order is appropriate. In some cases, the RPN is not able to get in touch with the prescriber in a timely fashion. This approach ultimately delays patient care, creates duplication and adds additional burden, and unnecessarily takes the prescriber away from other vital care. Authorizing RPNs with the knowledge skill and judgment to initiate these acts directly will relieve administrative burdens on both RPNs and current prescribers of these procedures and ensure that patients can receive the best care possible in a timely fashion.
Will these changes compromise patient safety?
Patient safety is and will always be our top priority. We believe these changes will enhance patient safety by ensuring timely access to care. Our position is that RPNs with the appropriate knowledge, skill and judgment should be able to initiate these acts. In addition, in accordance with their CNO standards, all RPNs have the judgment to determine when they are competent to safely perform a controlled act. We look forward to working with the College of Nurses to ensure qualified RPNs are performing these procedures in a safe and competent manner.
Will these changes make RPN and RN Scope of Practice essentially the same?
No. While RNs and RPNs study from the same body of knowledge, the depth and breadth of RN education is longer providing them with a greater foundational knowledge and as a result of this difference, the RN level of autonomous practice is different than that of the RPN. RPNs generally care for less complex, more predictable patients with lower risks of adverse outcomes while RNs care for more complex, less predictable patients with higher risks of adverse outcomes. The proposed changes to RPN scope of practice would not change this.
How many RPNs will be impacted by these changes?
Many of these procedures require RPNs to have additional, specialized knowledge and training beyond their basic nursing education. For this reason, a significant number of RPNs will not experience a change in their practice as a result of these scope changes. Generally, only RPNs that already have additional and specialized education in specific practice areas will be impacted.
Who was consulted in developing these proposed changes?
RPNAO worked with government, the College of Nurses of Ontario and other clinical experts through a robust two-year consultation to arrive at common-sense proposals that put patient safety and care above all else. These changes are supported by leaders in hospital, long-term care and other sectors.
What are the proposed changes to scope of practice?
In an effort to streamline care pathways, improve access to minor and routine care in the community and increase patient choice in where to obtain health care services, the Ministry of Health has directed the Council of the College of Nurses of Ontario to make the necessary regulatory amendments to authorize RPNs to independently initiate the following procedures:
- Irrigating, probing, debriding and packing of a wound below the dermis or below a mucous membrane;
- Venipuncture to establish peripheral intravenous access and maintain patency, using a solution of normal saline (0.9 per cent), in circumstances in which the individual requires medical attention and delaying venipuncture is likely to be harmful to the individual;
- Those that, for the purpose of assisting an individual with health management activities, requires putting an instrument, beyond the individual’s labia majora and for the purpose of assessing an individual requires putting an instrument, hand or finger beyond the individual’s labia majora; and
- Those that, for the purposes of assessing an individual or assisting an individual with health management activities, requires putting an instrument or finger into an artificial opening into the individual’s body.
These are all procedures that qualified RPNs perform regularly as part of their practice with an order.
Why has RPNAO advocated for changes to Scope of Practice?
A key part of our job is advocating for a strong health system, protecting patient safety and standing up for the interests of our members and the 45,000 RPNs across Ontario. Over the past several years, RPNs have told us how current regulations governing scope of practice create frustrating barriers that prevent them from delivering the best quality care to patients. Currently RPNs can only perform certain controlled act procedures with an order. We have heard from RPNs, patients, families and other care providers across the province that giving RPNs the ability to initiate procedures they already have the experience, expertise and authorization to perform will help ensure people who need help get it without delay. Patients who are in urgent need, including those in emergency or isolated situations, don’t have time to wait while an educated and competent RPN seeks permission to provide care they are qualified to give. This inefficient approach has a negative impact on the patient, the nurse and the broader health system that is already under strain. RPNAO has been advocating for modest changes to scope of practice to bring better care to our most vulnerable people and better value to our health system.
What are the next steps in this process?
The Ministry of Health has asked the College of Nurses to bring forward new regulations by June 30, 2020. Over the coming months, we will continue to work closely with the Ministry, the College of Nurses and other health system partners to realize these changes in a way that safeguards patient safety, supports RPN practice and delivers better value to our health system. As further information becomes available, we will keep our members informed.