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Bulletin

Regulated Health Professions in Ontario: Recent Updates

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Overview

Health Bulletin

In Ontario, 29 health professions (“Regulated Health Professions”)[1] and nearly 400,000 health care professionals are currently regulated by one of 26 “Colleges”.[2] These profession-specific regulatory Colleges are not-for-profit corporations established and governed by profession-specific statutes, such as the Medicine Act, 1991 and the Nursing Act, 1991 (the "Health Profession Acts") and Ontario’s Regulated Health Professions Act, 1991 (the "RHPA"). The Colleges are not educational, diploma or degree granting bodies (although they may provide their respective members with educational resources), but instead serve to protect the public. The purpose of this bulletin is to provide an overview of the legal and regulatory framework applicable to regulated health professionals in the Province of Ontario, and to provide clarity on the distinction between certain regulated health professionals – in particular, Physicians, Physician Assistants and Nurses, that commonly provide services within the same or a similar place. 

Background

Colleges are responsible for ensuring that the health care professionals they regulate provide services in a safe, professional, and ethical manner.[3] Colleges seek to uphold these obligations by, among other things, setting standards of practice, developing quality assurance programmes, and establishing standards of professional ethics. The Health Professions Procedural Code (which is Schedule 2 to the RHPA, but is incorporated into every Health Profession Act) (the "Code") establishes a lengthy list of requirements that apply to Colleges, for example, in respect of registration of members, complaints and reports regarding members, and discipline members. The Code also describes the objects of each College – including, to:

  • regulate the practice of the applicable Regulated Health Profession in accordance with the profession-specific Health Profession Act, the Code, the RHPA and the regulations to which the College is subject; and
  • develop, establish and maintain standards of qualifications for the applicable health professionals to be issued certificates of registration by the College (which certificates permit the professional to practice the profession in the Province, subject to any restrictions set out therein).

A full list of the Colleges’ objects, as set out in the Code, is included at the end of this bulletin.

Distinguishing Roles of Health Care Providers

With the creation of greater roles and responsibilities as health care providers continue to meet increasing health care needs, it is useful to distinguish between various health professions who often provide health care services within the same environment. The following chart provides a high-level summary of the:

  • College;
  • Health Profession Act;
  • educational requirements; and
  • scope of practice,

applicable to or of physicians, physician assistants ("PAs"), and each class of registration of nurses[4] (which includes, registered practical nurses ("RPNs"), registered nurses ("RNs"), and nurse practitioners ("NPs")). We note that Ontario is following in the footsteps of other provinces, including Alberta, Manitoba and New Brunswick to regulate PAs via amendments to the Medicine Act, 1991 (the "Medicine Act") (which amendments have been passed but are not yet in force). PAs are a relatively new profession in Ontario, having been introduced to the province’s health care system in 2007 through a joint initiative of the Ministry of Health and the Ontario Medical Association.[5] According to the Canadian Physician Assistant Association, there are currently approximately 500 PAs in Ontario.[6]

The term “scope of practice” is used to refer to the scope of practice statement that describes the activities of a Regulated Health Profession, including any “controlled acts” that members of the Regulated Health Profession are authorized to perform.  “Controlled acts” are those acts (including procedures and activities) that have been determined to pose a risk to the public if not performed by a qualified health professional – e.g. communicating a diagnosis,[7] and administering a substance by injection or inhalation. The RHPA prohibits any person from performing a controlled act in the course of providing health care services to an individual, unless:

  1. the person is authorized by a Health Profession Act to perform such controlled act (an Authorized Practitioner); or
  2. the controlled act is being performed on delegation from an Authorized Practitioner.[8] 

The chart below provides a high level summary only and is subject to other restrictions set forth by the applicable regulatory college and the applicable legislation. We note that amendments to the scope of practice of NPs, RPNs and RNs are proposed but not yet in effect. Therefore, we recommend that you check the Nursing Act, 1991 (the "Nursing Act") and the regulations made thereunder in considering the scopes of practices of nurses.

 

Physician [9]

Physician Assistant [10]

NP [11]

RN [12]

RPN [13]

College

College of Physicians and Surgeons of Ontario (“CPSO”)

Currently not regulated by any College – will be regulated by the CPSO[14]

College of Nurses of Ontario (“CNO”)

CNO

CNO

Health Profession Act

Medicine Act

Currently not regulated under an Act – will be regulated under the Medicine Act[15]

Nursing Act

Nursing Act

Nursing Act

Educational Requirements

A medical degree obtained by graduating from either an accredited medical school or an acceptable unaccredited medical school.

Completion of a university degree in a physician assistant education program.

Graduation from a College of Nurses of Ontario-approved university NP program that grants a certificate in one of the following specialties: adult, pediatric, or primary health care.

A baccalaureate degree in either a collaborative college-university nursing program or a four-year university nursing program, both leading to a Bachelor of Science in Nursing degree or Bachelor of Nursing degree. An RN’s education is more comprehensive than an RPN’s.

A diploma in Practical Nursing from an accredited college program consisting of four semesters over two years. An RPN’s education is less comprehensive  and more focused than RNs or NPs.

Scope of Practice

 

Communicating a diagnosis[16]

 

[17]*

*May perform controlled acts only through delegation from physician.

The scope of a PA’s practice is thus highly dependent on the specific physician-PA relationship. Under upcoming amendments to the Medicine Act, PAs will only be permitted to perform an act under delegation if the performance is permitted by the regulations. [18]

Performing a procedure on the tissue below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth[19]

*

*Limited to performing a procedure on the tissue below the dermis or below the surface of a mucous membrane. May initiate procedure and provide an order to an RN or RPN to perform this procedure as well. 

*

*Limited to performing a procedure on the tissue below the dermis or below the surface of a mucous membrane. [20] May initiate procedure and provide an order for an RPN to perform this procedure as well.

*

*Limited to performing a procedure on the tissue below the dermis or below the surface of a mucous membrane. [21] May initiate procedure but not provide an order to another nurse (or any other person) to perform.

Setting or casting a fracture of a bone or a dislocation of a joint

Moving the joints of the spine beyond the individual’s usual physiological range of motion using a fast, low amplitude thrust

Administering a substance by injection or inhalation

*

*Limited to circumstances where the procedure has been ordered by a member of the CPSO (a physician) or a member of any other College who is authorized to order the procedure, or where: (i) the NP has a nurse-patient relationship with the patient; and (ii) the procedure is performed only for therapeutic purposes.

✓*

*Limited to circumstances where the procedure has been ordered by a member of the CPSO (a physician), an NP (subject to the restrictions set out in the "NP" column) or a member of any other College who is authorized to order the procedure.

✓*

*Limited to circumstances where the procedure has been ordered by a member of the CPSO (a physician), an NP (subject to the restrictions set out in the "NP" column) or a member of any other College who is authorized to order the procedure.

Putting an instrument, hand or finger:

 

 

 

 

(i) beyond  the external ear canal

(ii) beyond the point in the nasal passages where they normally narrow

*

*For the purpose of assisting client with health management activities .[22] May initiate procedure and provide an order for an RPN to perform this procedure as well.

*

*For the purpose of assisting client with health management activities. [23] May initiate procedure but not provide an order to another nurse (or any other person) to perform.

(iii) beyond the larynx

*

*For the purpose of assisting client with health management activities .[24] May initiate procedure and provide an order for an RPN to perform this procedure as well.

*

*For the purpose of assisting client with health management activities. [25] May initiate procedure but not provide an order to another nurse (or any other person) to perform.

(iv) beyond beyond the opening of the urethra

     

 ✓*

* For the purpose of assisting client with health management activities . [26]  May initiate procedure and provide an order for an RPN to perform this procedure as well.

 ✓*

* For the purpose of assisting client with health management activities . [27]  May initiate procedure but not provide an order to another nurse (or any other person) to perform.

 

(v) beyond the labia majora

     

 ✓*

* For the purpose of assessing or, assisting the client with health management activities . [28]  May initiate procedure and provide an order for an RPN to perform this procedure as well.

 ✓*

* For the purpose of assisting the client with health management activities . [29]  May initiate procedure but not provide an order to another nurse (or any other person) to perform.

 

(vi) beyond the anal verge

   

 ✓*

*For the purpose of assessing or, assisting the client with health management activities. [30]  May initiate procedure and provide an order for an RPN to perform this procedure as well.

✓*

*For the purpose of assessing or, assisting the client with health management activities. [31]  May initiate procedure but not provide an order to another nurse (or any other person) to perform.

 

(vii) into an artificial opening into the body

   

✓*

*For the purpose of assessing or, assisting the client with health management activities. [32]

 

Applying or ordering the application of a form of energy prescribed by the regulations under the RHPA[34]    

✓*

* Ordering is limited to x-rays and ultrasounds; applying is limited to ultrasounds; NPs are not permitted to order CT scans, MRIs or nuclear medicine procedures

✓*

* Limited to applying ultrasounds on order from an Authorized Practitioner. 

✓*

* Limited to applying ultrasounds on order from an Authorized Practitioner. 

Prescribing, dispensing, selling or compounding a drug as defined in the Drug and Pharmacies Regulation Act, or supervising the part of a pharmacy where such drugs are kept  

✓*

* Limited to prescribing, dispensing, selling or compounding a drug

 

✓*

* Limited to prescribing, dispensing, selling or compounding a drug in accordance with the Regulation [35]

   
Prescribing or dispensing, for vision or eye problems, subnormal vision devices, contact lenses or eye glasses other than simple magnifiers        
Prescribing a hearing aid for a hearing impaired person        
Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance or a device used inside the mouth to protect teeth from abnormal functioning        
Managing labour or conducting the delivery of a baby        
Allergy challenge testing of a kind in which a positive result of the test is a significant allergic response        
Treating by psychotherapy[36]        

 

Updates Post-Bill 283

As described in our Health Law Group's previous bulletin, Ontario introduced Bill 283 in April of last year. Bill 283 received Royal Assent on June 3, 2021.[37]  Among other things, Bill 283:

  • as noted above, will amend the Medicine Act to include the regulation PAs under the CPSO;
  • introduces behaviour analysts as a new profession under the previous College of Psychologists of Ontario and updates the name of the college to the College of Psychologists and Behaviour Analysts of Ontario; and
  • establishes the Health and Supportive Care Providers Oversight Authority, a new regulatory body to oversee personal support workers (“PSWs”).[38]

Much of the legislation providing for the above changes is not yet in force, which is to be on a day or days proclaimed by the Lieutenant Governor. With respect to PAs, behaviour analysts, and PSWs, there are no substantial updates beyond our previous bulletin.

One recent development that relates to regulated health professions in Ontario, however, pertains to traditional Chinese medicine practitioners and acupuncturists. On March 10, 2022, the Ontario government amended Bill 88, Working for Workers Act, 2022, to remove the Traditional Chinese Medicine Repeal Act, 2022 (Schedule 5). Thus, the Traditional Chinese Medicine Act, 2006 and the RHPA continue to regulate members of the College of Traditional Chinese Medicine Practitioners and Acupuncturists of Ontario.[39]

We will continue to monitor for any further updates to regulated health professions in Ontario.

Schedule A – Objects of Regulatory Colleges

The Code describes the objects of each Regulatory College:

  1. To regulate the practice of the profession and to govern the members in accordance with the health profession Act, this Code and the Regulated Health Professions Act, 1991 and the regulations and by-laws.
  2. To develop, establish and maintain standards of qualification for persons to be issued certificates of registration.
  3. To develop, establish and maintain programs and standards of practice to assure the quality of the practice of the profession.
  4. To develop, establish and maintain standards of knowledge and skill and programs to promote continuing evaluation, competence and improvement among the members.
    1. To develop, in collaboration and consultation with other Colleges, standards of knowledge, skill and judgment relating to the performance of controlled acts common among health professions to enhance interprofessional collaboration, while respecting the unique character of individual health professions and their members.
  5. To develop, establish and maintain standards of professional ethics for the members.
  6. To develop, establish and maintain programs to assist individuals to exercise their rights under this Code and the Regulated Health Professions Act, 1991.
  7. To administer the health profession Act, this Code and the Regulated Health Professions Act, 1991 as it relates to the profession and to perform the other duties and exercise the other powers that are imposed or conferred on the College.
  8. To promote and enhance relations between the College and its members, other health profession colleges, key stakeholders, and the public.
  9. To promote inter-professional collaboration with other health profession colleges.
  10. To develop, establish, and maintain standards and programs to promote the ability of members to respond to changes in practice environments, advances in technology and other emerging issues.
  11. Any other objects relating to human health care that the Council considers desirable.[i]

[i] Special thank you to Rachel Hung, articling student and Amirali Alavi, summer student, for their contributions to this bulletin.

[1] The health professions regulated by the RHPA, and their corresponding professional statutes, are set out in Schedule 1 to the RHPA.

[2] Health Profession Regulators of Ontario (HPRO)

[3] Health Profession Regulators of Ontario (HPRO)

[4] We have not summarized the classes of registration for non-practising or “temporary” nurses.

[5] See HealthForceOntario’s website

[6] See the PA Fact Sheet on the Canadian Association of Physician Assistants' website.

[7] More specifically, “communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the diagnosis.” See section 27(2)1. of the RHPA.

[8]We note that not all controlled acts can be delegated. Whether a controlled act can be delegated depends on the act and the profession (and in some cases, the class of registration of) an Authorized Practitioner.

[9] Information gathered from the College of Physicians and Surgeons of Ontario’s webpage and the Medicine Act, 1991.

[10] Information gathered from the Canadian Association of Physician Assistants webpage, the College of Physicians and Surgeons of Ontario’s article, and the Medicine Act, 1991.

[11] Information gathered from the College of Nurses of Ontario’s Practice Standard on Nurse Practitioners [PDF], the Registered Nurses’ Association of Ontario’s webpage, and the Nursing Act, 1991.

[12] Information gathered from the College of Nurses of Ontario’s Practice Guideline on Authorizing Mechanisms [PDF] and Practice Standard on Decisions About Procedures and Authority [PDF], the Registered Nurses’ Association of Ontario’s webpage, and the Nursing Act, 1991.

[13] Ibid.

[14] This will occur through amendments to the Medicine Act to include PAs as a class of members of the CPSO. The referenced amendments are contained within Bill 283, An Act to amend and enact Various acts with respect to the health system (“Bill 283”) and will come into effect on proclamation of the Lieutenant Governor. See the last part of this bulletin for further information.

[15] Supra note 12

[16] More specifically, communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the diagnosis.

[17] PAs are health care professionals that work solely under the supervision of a physician, acting as “physician extenders” (see Supra note 7). According to the CPSO (see Supra note 7): “PAs are only able to perform controlled acts through delegation — where a physician temporarily transfers their authority to a PA, and ultimately the physician remains accountable and responsible for patient care.”

[18] No such regulations are yet in force. See Supra note 12.

[19] Including scaling of teeth.

[20] The CNO’s Practice Standard provides that RNs may do the following in respect of a wound below the dermis or mucous membrane: cleansing, soaking, irrigating, probing, debriding, packing and dressing.

[21] The CNO’s Practice Standard provides that RPNs may do the following in respect of a wound below the dermis or mucous membrane: cleansing, soaking, and dressing (which is more limited than the scope of practice set for RNs. See Ibid).

[22] Cannot initiate where the procedure is for the purpose of treating a health problem  (rather than assisting the client with this procedure).

[23] Cannot initiate where the procedure is for the purpose of treating a health problem  (rather than assisting the client with this procedure).

[24] Cannot initiate where the procedure is for the purpose of treating a health problem  (rather than assisting the client with this procedure).

[25] Cannot initiate where the procedure is for the purpose of treating a health problem  (rather than assisting the client with this procedure).

[26] Cannot initiate where the procedure is for the purpose of treating a health problem  (rather than assisting the client with this procedure).

[27] Cannot initiate where the procedure is for the purpose of treating a health problem  (rather than assisting the client with this procedure).

[28] Cannot initiate where the procedure is for the purpose of treating a health problem  (rather than assessing or assisting the client with this procedure).

[29] Cannot initiate where the procedure is for the purpose of treating a health problem.

[30] Cannot initiate where the procedure is for the purpose of treating a health problem  (rather than assessing or assisting the client with this procedure).

[31] Cannot initiate where the procedure is for the purpose of treating a health problem (rather than assisting the client with this procedure).

[32] Cannot initiate where the procedure is for the purpose of treating a health problem (rather than assessing or assisting the client with this procedure).

[33] Cannot initiate where the procedure is for the purpose of treating a health problem (rather than assisting the client with this procedure).

[34] The following forms of energy are prescribed by section 1 of O Reg 107/96 (“Controlled Acts”) under the RHPA: (1)  Electricity for aversive conditioning, cardiac pacemaker therapy, cardioversion, defibrillation, electrocoagulation, electroconvulsive shock therapy, electromyography, fulguration, nerve conduction studies, or transcutaneous cardiac pacing; (2) Electromagnetism for magnetic resonance imaging; and (3) Soundwaves for diagnostic ultrasound or lithotripsy.

[35] With respect to the prescribing of controlled drugs and substances, an NP is only permitted to do so if they satisfy the Executive Director (under the Nursing Act) that the member has, within any time period set by Council (of the CNO), successfully completed education approved by Council (which is referred to as “approved controlled substances education”) that was specifically designed to educate registered nurses in the extended class to safely, effectively and ethically prescribe controlled substances.

[36] More specifically, treating, by means of psychotherapy technique, delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgement, insight, behaviour, communication or social functioning.

[37] Bill 283, Advancing Oversight and Planning in Ontario's Health System Act, 2021

[38] Proposed Legislation to Strengthen the Health and Supportive Care Workforce During COVID-19 and Beyond, Ontario Newsroom

[39] Bill 88 Amended to Remove TCM Repeal Act, 2022                                                                                                                     

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