Ontario considers expanding scope of practice for nurses

In late June, the Ontario government announced it was consulting with the College of Nurses of Ontario in Toronto, Ontario, Canada, on expanding the scope of practice for nurse practitioners. The changes are being seen as a measure to address the province’s critical primary care shortage.

Ontario currently has more than 5,000 nurse practitioners. While their scope of practice varies by province, they can already diagnose, refer patients to specialists and prescribe medications in Ontario and several other provinces.

Proposed changes include allowing nurse practitioners to apply defibrillators and pacemakers, perform electrocautery to remove skin tags and treat lesions, and sign blood test forms for specific infectious diseases. The government is also considering changes to end-of-life care by allowing nurse practitioners to certify death in any circumstance or any registered nurse to certify an expected death (for example, during palliative care).

“By leveraging the full breadth of our training and expertise, nurse practitioners can play a critical role in ensuring a more integrated health care system. The proposed changes will lead to faster care, better outcomes and a more efficient health care system,” said Michelle Acorn, DNP, NP, CEO of the Nurse Practitioners Association of Ontario. Medscape Medical News.

Expansion of the scope of application

The proposed measures could help provide care more quickly, said Acorn, who has been a nurse for more than 25 years. Throughout her career, regulatory changes have helped nurses better apply their training in practice.

Nurse practitioners were given the authority to prescribe controlled substances in 2017 and to order CT scans and MRIs in 2022. The ability to prescribe certain medications was also expanded to all registered nurses in 2023. Still, “nurse practitioners are still an untapped resource right now,” Acorn added.

Now that nurses can perform these essential tasks, the new changes “are just some of the gaps that need to be addressed immediately to ensure they are fully optimized and integrated into Ontario’s health-care system,” Acorn said. Beyond the proposed changes, Acorn says allowing nurses to certify mental health forms is particularly important. “We absolutely have the knowledge, skills and judgment to do that.”

Some physicians, however, are hesitant to expand nurses’ scope of practice without ensuring patient safety. “Physicians value the essential contributions other health professionals make to the team, but we need a plan in place to ensure integration with the primary care system. If there is no integration plan or quality framework in place when expanding the scope of practice of health professionals, it will be detrimental to patient safety and the future of family medicine,” said the Ontario Medical Association (OMA). Medscape Medical News in a report.

“Our goal is to ensure that patients receive the care they need in an integrated system and to ensure that they do not fall through the cracks. This happens when there is a strong foundation in family medicine for primary care and broader health systems,” the OMA continued.

Nurse-led clinics

Tammy O’Rourke, a nurse, PhD and assistant professor at Athabasca University in Alberta, Canada, who supports the proposed changes, said allowing nurses to certify death could be particularly beneficial. Currently, doctors are responsible for signing the death certificate, which can be difficult for families who are suffering. “There is no legal requirement that a doctor certify the death, just that the paperwork be done by a doctor,” O’Rourke said. “And Ontario Health Insurance charges about $70 for that.”

While nurse practitioners now provide many of the same services as doctors, they can’t bill under the same fee-for-service model and are generally paid less than doctors, O’Rourke noted. That difference has led some nurses to open private clinics where patients pay out of pocket for primary care services — a practice that has sparked controversy. O’Rourke worked in a nurse-run private clinic in Belleville, Ont., from 2010 to 2014. Other reimbursement models are the best option, she said, but all providers should be paid the same for providing the same services.

Whether private clinics are a viable solution or not, changing the compensation system could help improve access to care, said Patrick O’Byrne, RN-EC, PhD, professor of nursing at the University of Ottawa, Ottawa, Ontario, Canada. Medscape Medical News. O’Byrne does not support private clinics as a system-wide intervention, although he does not criticize the nurses who work in them. He does, however, believe that nurse practitioners would benefit from direct access to fee schedules and billing.

‘Ripe fruit’

As for the proposed changes to scope of practice, “they made easy decisions,” O’Byrne said. While the changes are significant for a small number of people, he said they are not “a rate-limiting measure” for Ontarians to access care.

“Any move is a good step forward, but I don’t think it will have a huge, profound impact.” Instead, he believes bureaucratic barriers such as billing regulations need to be changed to ease the bottleneck in primary care.

“The longer the bottleneck persists, the more the public will say, ‘Give us nurse practitioners. We want access to quality care,’” O’Byrne said. “It becomes a turf war between the health professions, between medicine and nursing, but patients don’t care about the turf war. They want access to care.”

Gwendolyn Rak is a health journalist for Medscape Medical News based in Philadelphia.