This document discusses the history and current state of nurse practitioners in Ontario, Canada. It outlines how nurse practitioner roles began in the 1960s to address physician shortages, and have expanded over the decades. Currently there are over 1600 nurse practitioners in Ontario, though still only one for every 10 family physicians. The document also notes demographic trends toward an aging population that will increase healthcare demands and costs. It argues that optimizing nurse practitioner roles could help manage costs by improving access to primary care.

1. NURSE PRACTIONERS
OPTIMIZING OUR FUTURE
Karima Velji, RN, PhD
NPAO, 2010

2. OBJECTIVES
• Where have we come from? Why?
y
• Where are we now?
• Where are we going?
• Optimizing our future….

3. Where have we come from?
1960's
• First NP program established at the University of
Colorado.
• First education program for NPs working in northern
p g g
nursing stations began at Dalhousie University.
• Canada’s health care system was experiencing:
– changing role of the nurse from generalist to
specialist;
– a physician shortage (ratio 740:1) especially in rural
areas;;
– trend towards specialization in medicine, fewer MDs
in primary care; and
– emphasis on the curative aspects of medicine.
History slides source: NPAO website; Jane Sanders (2010)

4. Where have we come from?
1970's
• Boudreau Report recommends expanded role of the RN
and first university program in Ontario to prepare
expanded role RNs.
• First university based program to prepare expanded role
RNs.
• NPAO established as an affiliated Interest Group of the
RNAO. O
• CNA/CMA Joint Committee releases joint policy
statement on the role of the NP.
• Ontario Council of Health releases The Nurse
Practitioner in Primary Care.
History slides source: NPAO website; Jane Sanders (2010)

5. Where have we come from?
1980's
• First round of NP initiative falters.
• NP education program closes at McMaster University.
• NPAO continues to actively lobby to re-establish
educational programs in Ontario.
• Development of first ACNP Program "Expanded Role
Program,
Nurse" program – Neonatology.
• CNS-NP role implemented in Level 3 NICUs following
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reduction in number of pediatric residents.
History slides source: NPAO website; Jane Sanders (2010)

6. Where have we come from?
1990s
• HPRAC releases 8 recommendations in support of
legislative authority for PHCNPs.
• Bill 127, the Expanded Nursing Services for Patients Act
is proclaimed.
• NPAO expands its mandate to include all nurse
practitioners.
• Teaching hospitals express interest in ACNP role.
History slides source: NPAO website; Jane Sanders (2010)

7. Where have we come from?
1990's
• Government announce a new Nurse Practitioner
Initiative to improve access to PHC.
• Council of Ontario University Programs in Nursing
(COUPN) consortium develops the new PHCNP
Program.
• Post-Masters ACNP certificate programs Toronto and
London.
• College of Nurses of Ontario (CNO) approves the
Extended Class registration.
History slides source: NPAO website; Jane Sanders (2010)

8. Where have we come from?
2000’s
• Approvals for Nurse Practitioner led clinics.
• HPRAC - Bill 179 – expanding mandate for NPs.
• Regulation 965 – PHA - lobbying on admit, transfer,
discharge elements.
• Removal of MAC oversight on NP NP.
History slides source: NPAO website; Jane Sanders (2010)

9. Where are we now?
• We have grown from 1001 NPs (PHC) in 2008 to 1694
(1262 PHC, 133 P di t i 307 adult) i O t i
PHC Pediatric, d lt) in Ontario.
• Approvals for 26 NP led clinics.
• Integration in all sectors; legislative barriers p
g g partially
y
removed.
• Since 1974, 28 RCTs have consistently shown that
nurse practitioners are effective, safe practitioners and
can positively influence patient, provider and health-
f
system outcomes.
• While there has been a steady increase in the supply of
family doctors and nurse practitioners ,there is still only
f il d t d titi th i till l
one nurse practitioner for every 10 family physicians in
the province.
History slides source: NPAO website; Jane Sanders (2010); CHSRF mythbusters, 2009

10. Where are we now?
• Canadians are highly satisfied with care p
g y provided byy
nurse practitioners. A 2009 Harris/Decima poll of 1,000
Canadians found that:
– one i fi h b
in five has been t t d b a nurse practitioner;
treated by titi
– majority would like to see the role expanded;
– greater than three in four would be comfortable
seeing one in lieu of their family doctor; and
– four in five feel that expanding their roles would be an
effective way of managing healthcare costs.
(Source: CHSRF mythbusters, 2009)

11. Where are we now?
HPRAC – Bill 179
• Royal assent in December 2009, awaiting regulations.
• Removal of historic barriers – e.g. broader range of
drugs and forms of energy.
• Regulation 965 under the Public Hospital Act currently
limiting scope and potential system impact transfer of
impact,
patients.
• Advocacy to enable RN(EC)s to provide health services
to hospitalized in-patients (without directives).
(Source: NPAO, 2010)

12. Cost of health care
• Today, health sector spending accounts for about 46
y, p g
cents of every program dollar. If left unchecked, cost
drivers could push health care spending to 70 cents of
every program dollar in 12 years Health sector expense
years.
is projected to increase by $6 billion from 2009-10 to
2012-13.
Source of health expenditures slides: MOHLTC Ontario website (2010)

13. Per-Capita Health Spending by Age Group, 2007
Per-Capita Provincial Government Health Spending, by Age Group,
Ontario, 2007, Current Dollars
Age Spending Per Share of Population, Share of
Group Person ($)1 2007 Population, 2030
Actual (Per Cent) Projection (Per
Cent)
<1 9,188.0 1.1 1.1
1–4
1 4 1,292.6
1 292 6 4.4
44 4.3
43
5–14 1,047.6 12.0 11.2
15–44 1,706.3 42.8 37.3
45–64 2,823.6 26.5 24.2
65+ 10,330.7 13.2 21.9
65–74
65 74 6,883.1
6 883 1 6.9
69 11.7
11 7
75–84 11,843.7 4.7 7.4
85+ 20,702.4 1.6 2.8
Total 3,127.0 100.0 100.0
1Weighted average. Sources: Canadian Institute for Health Information, Statistics
Canada and Ontario Ministry of Finance population projections (Fall 2009).

14. Demographic shift
• Currently, 13 percent of the population is 65 years of age
or older. By 2016, there will be six million seniors in
y ,
Canada, composing 16 percent of the population. In
Ontario, there are now approximately 1.5 million seniors,
representing 40 p
p g percent of Canada's seniors. That
number is expected to double by 2028 (Ontario Seniors'
Secretariat, 2003).
• The demographic profile of Ontario is one of an aging
society. In 2009, 6.5 percent of Ontarians were over the
age of 75 years, up from 4.6 percent in 1991. Projections
indicate that in twenty years 10 6 percent of the
years, 10.6
population will be over 75 years old. The total
dependency ratio (the ratio of the population aged 0-19
and 65+ to the population aged 20-64) will be up to 79 279.2
percent.
MOHLTC Ontario (2010)

15. Demographic shift
• Dramatic increases in the number of seniors living in
long-term care institutions. 38 percent of women and 24
l t i tit ti t f d
percent of men 85 years and older live in an institution.
• For many seniors, home care is the preferred method of
receiving care. O i f
i i One in four people placed i LTC could
l l d in ld
potentially be cared for in alternative settings.
• 90 percent of older seniors living in long-term care
institutions suffer from a mental disorder. In Ontario 88
disorder Ontario,
percent of these institutions receive only five hours or
less of psychiatric services per month for the entire
resident population.
population
• Shortly after entering an LTC home, one in six residents
receives a new antipsychotic drug that he or she was not
taking before, and one in four receives a new drug for
anxiety or sleep.
Quality Monitor OHQC (2010)

16. Wait times
• Wait times for an LTC bed are too long — an average of
105 days, or more than th
d th three months. F people waiting
th For l iti
while at home, the wait time is 173 days (almost half a
year). Wait times have tripled since the spring of 2005.
• F il i di id l who cannot go h
Frail individuals h t home t i ll spend 53
typically d
days in hospital waiting for placement. As a result,
currently 16% of all hospital beds in Ontario are
occupied by patients designated as ALC who do not
ALC,
need to be in hospital.
• In 2009 25% of patients spent more time in the ED
receiving care than the recommended target The
target.
majority of patients did not get to see a physician
within the timeframe recommended by national experts.
About 6% of them left the emergency department before
being seen.
Quality Monitor OHQC (2010)

17. Primary care
• About 7.1% (730,000) of Ontarians continue not to have
a f il d t Ab t h lf of th
family doctor; About half f these i di id l are
individuals
actively looking but can’t find one.
• For people who already have a family doctor, only half
can see th i d t th same or next day when sick.
their doctor the td h i k
• Compared to 10 other countries, Ontario and Canada
have the worst record on timely access to primary care.
Almost nine in 10 O Ontarians say they are waiting too long
to see their doctor, and this indicator has gotten worse in
the last three years.
• I the last six years, the per capita supply of family
In th l t i th it l f f il
doctors has increased by 6.2%, and that of nurse
practitioners by 82%.
Quality Monitor OHQC (2010)

18. Health promotion
• Half of Ontarians are not getting enough exercise, one in
six are smoking and one in five are heavy drinkers.
• Breastfeeding rates are increasing and teen pregnancy
rates are decreasing, but there is still room to improve.
• One-quarter of the p p
q population does not g necessary
get y
health prevention services (e.g., pap tests,
mammography and flu shots).
• •People with low incomes or poor education are at
higher i k f h lth behaviors and not getting h lth
hi h risk of unhealthy b h i d t tti health
prevention services.
• Only 13% of Ontario doctors routinely provide patients
with a li t of medications t k
ith list f di ti taken, with 46% never
ith
providing a list.
• About one in five seniors aged 65 and over are on a
medication with potentially dangerous side effects
effects.
Quality Monitor OHQC (2010)

19. Chronic disease management
• While complications from diabetes have decreased
significantly over the past five years, patients are still
not getting the regular monitoring of their condition and
risk factors that they need.
• Only half of patients with diabetes have their eyes and
feet examined and slightly fewer than half are getting the
medication they needneed.
• The number of patients who die within one year of
having a heart attack has improved slightly to one in 11,
but
b t we can still d b tt
till do better.
Quality Monitor OHQC (2010)

20. Quality - ECFAA
• On June 8, 2010, the Excellent Care for All Act, 2010 (ECFAA)
received Royal Assent Beginning with hospitals the Act requires
Assent. hospitals,
health care organizations to:
– Develop and post annual quality improvement plans.
– Implement p
p patient and employee satisfaction surveys and a
p y y
patient relations process.
– Link executive compensation to achievement of quality plan
performance improvement targets.
– Develop declarations of values after public consultation
consultation.
– Create quality committees to report to each hospital board on
quality related issues.
– Related amendments to Regulation 965 under the Public
g
Hospitals Act (PHA) were made and filed to support ECFAA.
• The MAC would no longer be required to make recommendations to
the board under s.7(2)(a)(v) of Regulation 965 under the PHA that
relate to the quality of care provided by extended class nurses who
are hospital employees.
Quality Monitor OHQC (2010)

21. Where are we going?
RNAO calls for:
• Implementation of campaign commitment for funding
for 25 additional NP-led clinics.
• Implementation of funding for 150 new Nurse.
• Practitioner (NP) Primary Health Care positions across
health centres, family health teams, emergency
departments,
departments and other outpatient settings
settings.
• The removal of legislative and regulatory barriers to
enable RN(EC)s to practice to their full scope.
• Dedicated funding to enhance the management of
chronic disease in Ontario.
RNAO (2010)

22. Optimizing our future
• Appropriate numbers and utilization of NPs; funding
pp p g
streams for the positions.
• Removal of legislative barriers.
• Examine and respond actively the drivers for inclusion of
NP roles in primary and institutional settings.
• Demonstrate value in enhancing access, quality, equity,
appropriateness and cost effectiveness.
i t d t ff ti
• Stay true to patient need and system focus and don’t
lose “nursing” component of the role.
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