Nurse practitioners (NP) now have the legislated authority to admit, treat and discharge hospital patients. According to the Ministry of Health and Long-term Care (MOHLTC), these changes were initiated in order to provide Ontario hospitals with a new health provider option for admission, treatment and discharge planning to optimize the use of health human resources and increase access to care while reducing wait times and improving delivery of patient-centred care[1].
See more on legislation.
RNAO supports the MOHLTC’s changes because enabling NPs to admit inpatients to hospitals will:
- Increase access to timely care for Ontarians
- Enhance co-ordination and continuity of care, both within hospitals and in the community (such as long-term care and primary health)
- Improve delivery of patient-centred care and reduce fragmentation of the client experience
- Enhance quality and safety of patient care
- Improve patient flow through the system and increase hospital efficiency
- Reducing emergency department (ED) wait times
- Decreasing length of stay through timely discharge
- Decreasing rates of re-admission through discharge planning
- Optimize utilization of health human resources and of NP competencies
- Enhance inter-professional collaboration
- Use Ontario’s health-care resources more effectively and efficiently [2]
RNAO believes that it is in the best interest of Ontarians for NPs to admit patients to hospitals. The regulatory framework exists to make this a reality; however, it is up to each hospital to amend its by-laws and policies to enable full utilization of NPs. Effective admission, treatment and discharge processes work best hand-in-glove: more admissions facilitated by NPs will contribute to the overall effectiveness of care of the hospital patient [3].
Who benefits from NP admission?
| Patients | Hospital | Health System | Human resource capacity, geography and access to care |
|---|---|---|---|
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For further information about the benefits of NPs caring for hospital patients please see Quality of Care: Improving Outcomes through Care by NPs.
NP admission: Not an act but a process of care
Admission and discharge processes in hospitals are increasingly a focus for quality improvement initiatives. Streamlining the process of care requires viewing admission to hospital as a process of providing care, and not as a single act. Continuity of care provider is facilitated by having the most appropriate care provider admit the patient. Authorizing NPs to admit reduces duplication of assessments, enhances the continuity of caregiver and enables a more satisfying therapeutic relationship to be established. Furthermore, the need for time-consuming and inefficient medical directives is eliminated [3].
Collaborative, interprofessional models of care are of greatest benefit to patients, hospitals, and the health-care system[4]. Collaboration with a team, however, requires NPs to have capacity to enact the whole plan of care. Under many existing models of care, the physician team member, who may be the least accessible, is the only one able to admit and discharge a patient to hospital. This gate keeping role is at odds with timely team-based actions. Therefore, advancing progressive models of care requires the NP to be an equal partner with physicians and other professionals as indicated by the patients’ needs.
Some Ontario examples of innovative models utilizing NPs to admission include:
- Central East LHIN’s GAIN Geriatric Clinic (Geriatric Assessment and Intervention Network), which establishes the admission from urgent/emergent clinics for seniors at four hospitals (Lakeridge, Rouge Valley, Scarborough & Peterborough) to ACE (Acute Care of the Elderly) in-patient units[5].
- NP-led C.A.R.E. model of Lakeridge Health, Complex Continuing Care. NPs admit, treat and discharge patients as the Most Responsible Provider (MRP) within an inter-professional team [6]. Lakeridge has received provincial, national and international recognition for this innovative model.
For more information, please see Models of Care.
Practice competencies for NP admission
As regulated health professionals, NPs are accountable for adhering to the College of Nurses of Ontario(CNO) Nurse Practitioner Practice Standard[7]. No credentials, other than those required by the CNO, are needed for NPs to practise to their full scope. Each NP can exercise their authority to admit as it is relevant to their practice setting and specialty.
Furthermore, providing additional authority to a regulated health professional does not require all members of that profession to actually exercise their full authority. As self-regulating professionals, NPs use their knowledge, skill and judgment to exercise authorities within their scope of practice based on their individual level of competency [7]. Each NP is responsible for practicing in accordance with the standards of the profession, and for keeping up to date with changes to NP practice throughout her/his nursing career.
NP admission and hospital by-laws
There is variability in admission policies across Ontario hospitals. In order to authorize NPs to admit, individual hospital by-laws need to be reviewed; this would serve to identify and eliminate barriers to NPs working to full scope of practice, and to create consistency of practice and policy across the province.
Amendments to hospital by-laws and to enable NPs to exercise full authority to admit/discharge may include, but are not limited to:
- Revising privileged staff by-laws
- Including NPs in most responsible provider (MRP)policies
- Modernizing medical advisory committees (MACs) to reflect interprofessional models of care, and ensuring NP representation on these committees
Policy change is only a first step; discrepancies may exist between legislation and regulation, hospital by-laws and policies, and front-line practice. These discrepancies may persist when changes are not effectively communicated and/or practice settings are resistant to change. In order to enact a smooth transition and effect the required changes, hospitals must lead, embrace and manage this organizational change to allow NPs to work to their expanded authority.
For further information, see Tools for Implementation.
Credentialing and privileging NPs for admission
In order to admit inpatients, NPs who are employed by hospitals do not require privileging and/or credentialing, whereas NPs who are not employed by the hospital do. For example, in some areas of the province, NPs working in primary care may require privileging in order to care for their patients who are hospitalized.
Furthermore, hospital boards must identify the criteria for appointment and re-appointment of NPs. This may require amendments to professional staff by-laws. Having an NP on the privileging and credentialing committee may be advantageous.
The goal of privileging is to:
- Assure high quality patient care
- Mitigate hospital and partnership risks
- Provide a clear and standardized process to ensure consistency across the sites and corporation
- Provide privileges that may expand based on evolving clinical mastery, advanced training, and increased services required
- Supervise practice initially, expanding to a more autonomous level of performance as efficacy and safety is assured and
- Link with the CNE and Lead NP/ NP Professional Practice Leader in order to support quality NP practice
The general process for hospital credentialing and privileging is as follows:
- Data is collated for the credentialing committee (regarding the NP’s proof of registration, certification, educational preparation, proof of malpractice insurance, proof of skill performance) and is approved
- The privileging committee grants privileges to the practitioner
- The medical advisory committee approves
- The hospital board approves
- A letter is sent to the NP from the CEO of the hospital, the program leader and the physician leader, which outlines the scope and limitation of the privileges granted
See an example of hospital by-laws revised to include NP privileging.
NP admission and liability
Under the Regulated Health Professions Statute Law Amendment Act, 2009 (Bill 179), all health professionals in Ontario are required to hold professional liability insurance. In response to this requirement, CNO has introduced amendments to its General By-Laws (article 44.4) to require all members to hold Professional Liability Protection (PLP).
Currently, most NPs in Ontario hold professional liability insurance obtained through the Canadian Nurses Protective Society (CNPS), which automatically provides occurrence-based professional liability coverage to NPs in Ontario who are members of RNAO and who are registered with the College of Nurses of Ontario (CNO) as an RN (Extended Class).
For details on professional liability considerations regarding admission and discharge, please click here for a presentation by the CNPS.
· Canadian Nurses Protective Services (CNPS) presentation 2012
NP admission and fair compensation
Hospitals considering implementing NP admission should use a salary-based model that is consistent with the current compensation model for NPs in hospital settings. There should also be sustained, dedicated funding for hospital-based NP positions. When NPs are funded largely from global hospital budgets this threatens their positions in times of fiscal change. If on-call stipends are provided to other on-call health-care providers, NPs should also receive this compensation[8]. According to a Cochrane review, team-based incentives are not seen as a fair and equitable way to foster interprofessional team collaboration or quality of care [9]and should be discouraged. Finally, all referrals to specialists, including those from NPs, should be compensated at the same rate.
References
1. Ontario Ministry of Health and Long-Term Care. Proposed amendments to Regulation 965 made under the public hospitals act. 2011 [cited 2015 June 24]; Available from: http://www.ontariocanada.com/registry/view.do?postingId=6182&language=en.
2. Nurse Practitioners' Association of Ontario. Submission to HealthForceOntario (HFO): Response to HealthForceOntario (HFO) Consultation on Nurse Practitioner Authority to Admit, Transfer and Discharge In-patients. 2010 [cited 2015 June 29]; Available from: http://npao.org/wp-content/uploads/2011/10/NPAO-Submission-to-HFO-re-Adm....
3. Registered Nurses' Association of Ontario. RNAO submission to Minister Matthews on NP admit, treatment, transfer and discharge. 2011 [cited 2015 June 19]; Available from: http://rnao.ca/policy/submissions/proposed-amendments-regulation-965-mad....
4. Van Soeren, M., Hurlock-Chorostecki, C., Reeves, S., The role of nurse practitioners in hospital settings: Implications for interprofessional practice. Journal of Interprofessional Care, 2011. 25(4): p. 245-251.
5. LHIN, C.E. Shorter Wait Times and More Healthcare Access for Seniors in the Central East LHIN. 2010 [cited 2015 July 10]; Available from: http://www.centraleastlhin.on.ca/Page.aspx?id=18810.
6. Gillard, L. Patient C.A.R.E the focus at Lakeridge Health Whitby. 2005 [cited 2015 July 10]; Available from: http://hospitalnews.com/patient-care-the-focus-at-lakeridge-health-whitby/.
7. College of Nurses of Ontario. Practice Standard: Nurse Practitioner. 2011.
8. van Soeren, M., et al., Report to Ontario Ministry of Health and Long-Term Care: The Integration of Specialty Nurse Practitioners into the Ontario Healthcare System. 2009.
9. Scott, A., et al., The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database of Systematic Reviews 2011(9 Art. No.: CD008451).