Health Professions Council
Registered Nurses
Scope of Practice Preliminary Report

FOREWORD

This report is the result of the Health Professions Council's review of the scope of practice of nursing by registered nurses (RNs) pursuant to the Terms of Reference from the Minister of Health and Minister Responsible for Seniors. Under the Health Professions Act, the Health Professions Council is a six-person advisory body appointed by the Government of British Columbia to make recommendations to the Minister of Health and Minister Responsible for Seniors about the regulation of health professions.

In this report the Health Professions Council examines how the existing scope of practice of nursing by RNs should be legislatively defined in order to reflect fairly and accurately the current state of practice and the public interest in the practice of nursing by RNs.

EXECUTIVE SUMMARY

The Health Professions Council has conducted a review of the scope of practice of nursing by RNs.

The purpose of the review is to provide recommendations to the Minister of Health and Minister Responsible for Seniors regarding four matters: scope of practice statements, reserved acts, supervised acts, and reserved titles.

The Health Professions Council has conducted a detailed consultation process and its recommendations regarding the four elements of the scope review are as follows:

1. The Council recommends the following scope of practice statement for registered nurses:

   The practice of nursing by registered nurses is the provision of health care for the promotion, maintenance and restoration of health and the treatment and prevention of illness and injury, primarily by assessment of health status, planning and implementation of interventions, and co-ordination of health services.

2. The Council recommends the following reserved acts be granted to registered nurses:

   Performing the physically invasive or physically manipulative act of putting an instrument, hand or finger(s):

   1. into the external ear canal, up to the eardrum, but excluding cerumen management,

   2. beyond the opening of the urethra,

   3. beyond the labia majora, but excluding the insertion of intrauterine devices, or

   4. beyond the anal verge.

3. The Council recommends that the following reserved acts be granted to registered nurses to perform only if the act is ordered by a health practitioner who is authorized by legislation to perform the act:

   [a.] Performing the following physically invasive or physically manipulative acts:

   1. procedures on tissue below the dermis, below the surface of a mucous membrane, and in the surface of the cornea;

   2. administering a substance by injection, inhalation, irrigation, or instillation through enteral or parenteral means;

   3. putting an instrument, hand or finger(s)

      1. beyond the point in the nasal passages, where they normally narrow,

      2. beyond the pharynx, or

      3. into an artificial opening into the body.

   [b.] Administering by any means a drug listed in Schedule I or II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act.

4. The Council recommends that a provision be enacted which sets out the duties of a health professional and his or her regulatory college when delegating a reserved act. The provision should require the following:

   • The assigning health professional's governing body must provide assent to the proposed reserved act being performed by someone else;

   • The reserved act to be assigned as well as the level of supervision must be clearly defined and circumscribed by the assigning health professional's governing body;

   • Where the person to whom the act will be assigned is a member of a self-regulating health profession, his or her governing body must approve of the assigning of the reserved act;

   • The instruction to perform the act must be made in writing either by way of a general written protocol or through a case-specific instruction;

   • The assigning health professional must be satisfied that the individual who will be performing the act has the necessary skills and training to perform the act safely;

   • The assigning health professional must ensure that the person who will be performing the act accepts the assignment.

5. The Council recommends that the following titles be reserved for members of the profession:

   • Registered Nurse,
   • R.N.,
   • Licensed Graduate Nurse, and
   • L.G.N.

6. The Council recommends that the title "nurse" be reserved for registered nurses, registered psychiatric nurses, licensed practical nurses, and Christian Science nurses.

7. The Council recommends that the name of the regulatory body, the "Registered Nurses Association of BC", be changed to the "College of Registered Nurses of British Columbia".

I.     INTRODUCTION

A. THE NATURE OF THE REVIEW

This is the preliminary report of the review of the scope of practice of nursing by RNs by the Health Professions Council (Council).

The review was conducted pursuant to Terms of Reference issued by the Minister of Health and Minister Responsible for Seniors in accordance with section 25 of the Health Professions Act, RSBC 1996, c. 183 (HPA). The Terms of Reference direct the Council to review the scopes of practice of the recognized health professions, of which nursing by RNs is one.

The Terms of Reference, which are included as Appendix A to this report, indicate that there are four main elements to the scope of practice review:

1. scope of practice statements which describe what the profession does, the methods it uses and the purpose for which it does it;

2. reserved acts which are those acts that present such a significant risk of harm that they should be performed only by professionals who are qualified to perform them;

3. supervised acts which are reserved acts, or aspects of reserved acts, which may be performed by persons supervised by health professionals; and

4. reserved titles which are titles that describe a profession's services and which are reserved exclusively for the health profession.

B.     THE PROCESS FOR THE REVIEW

The general process for the review provides for an initial meeting with the profession, submission of briefs by the regulatory body and professional association, a consultation process involving the health profession and interested parties regarding the profession's submission, drafting of a preliminary report, public hearings and a final report.

The Council held an initial meeting with the Registered Nurses Association of BC (RNABC) on April 19, 1995.

On July 5, 1995, the RNABC made a scope of practice presentation to the Council. It then submitted its brief on July 28, 1995. On September 19, 1995, the Council met with the RNABC to conduct an initial discussion of its brief. The submission was then summarized and distributed to interested groups and individuals including other regulated and unregulated health professions, teaching facilities and other provinces. Many responses were received. Thereafter, the Council met with representatives of the RNABC on June 5, 1997 and with a representative of the British Columbia Nurses Union (BCNU) on May 8, 1997 to discuss the review.

In 1998, the Council issued the Shared Scope of Practice Model Working Paper (Working Paper) which described in more detail the regulatory model set out in the Terms of Reference.

In March 1999, the BCNU and the RNABC made a joint submission to the Council which substantially revised the earlier RNABC submission. This submission was sent out to all health professions and interested parties. In August, 1999, the BCNU made a further submission regarding the title "nurse".

The Council carefully considered all of the information it received in drafting this report.

This report will be circulated to all health professions and other interested parties who participated in the Council's consultation process. A public hearing will be held on May 15 and 16, 2000 after which a final report will be issued. Persons or organizations who have made written responses to either the original consultation letter or to this preliminary report will be invited to speak at the hearing.

Throughout this report, the Council makes reference to the submissions of the RNABC and the BCNU and to the responses received during the consultation process. The Council has abbreviated its references to many of the responses received and for ease of reference, has included as Appendix C a glossary and abbreviations of names used in this report.

This review of nursing by RNs is being conducted concurrently with the Council's review of nursing by registered psychiatric nurses (RPNs) and nursing by licensed practical nurses (LPNs).

C.     THE REGULATION OF REGISTERED NURSING

Professional organization of nursing in Canada began with the International Council of Nurses in 1899 and the Canadian Nurses Association which was established in 1908 as the Canadian National Association of Trained Nurses. By 1922, every Canadian province had enacted some form of legislation for nursing. Nursing by RNs has been a self-regulating profession in British Columbia since the passage of the Registered Nurses Act in 1918. That Act established the Graduate Nurses Association of BC as the body responsible for regulating nursing by RNs. The name was changed to the Registered Nurses Association of BC by the repeal and replacement of the Act in 1935. Numerous amendments have since taken place. The Nursing Statutes Amendment Act, SBC 1988, c. 51, replaced the provisions respecting titles with limitations on both the use of "registered nurse" and "nurse". The Health Professions Statutes Amendment Act, 1993, introduced amendments to the duties and objects of the RNABC, its inspection powers, and its interim suspension powers in professional disciplinary matters. The current act is called the Nurses (Registered) Act , RSBC 1996, c. 336.

II.     THE POLICY BACKGROUND

The main impetus for a scope of practice review was the Report of the British Columbia Royal Commission on Health Care and Costs (Seaton Commission). The Seaton Commission stated that the existing legislation governing the health professions creates persistent jurisdictional disputes and a distinct lack of cooperation among the health professions, despite the fact that all health professional colleges have the same mandate - to protect the public from preventable harm.

The Seaton Commission stated that the primary reason for the jurisdictional disputes was the present regulatory system's reliance on exclusive scopes of practice. Under the exclusive scope of practice model, the various health professions have been granted an exclusive right to practice within a legislatively defined scope of practice. No one, other than a member in good standing of that profession, can perform acts within the profession's scope of practice unless they are granted an exemption.

The Commission concluded:

...exclusive scopes of practice should be narrowed to focus on preventing harm, as has been initiated recently in Ontario. We believe that more appropriate, cost-effective and timely health care could be provided to more patients if B.C. were to follow the Ontario initiative.

(Closer to Home, The Report of the Royal Commission on Health Care and Costs in British Columbia, Volume 2, 1991, p. D-33)

This recommendation is also consistent with legislative initiatives underway in Alberta.

The Seaton Commission was not the first review body to suggest that the present legislative model of exclusive scopes of practice was inappropriate. Restricting professional monopolies (exclusive scopes of practice) was also recommended in an earlier study commissioned by the British Columbia Minister of Health. In discussing the conflicts which may arise between the professional college and the public interest, the issue of exclusive scopes of practice was raised:

It must be emphasized that any professional legislation which unduly restricts the scope of practice of skilled personnel may be contrary to the public interest in greater supply and accessibility of service through the development of team practice. Therefore, it is urged that: Professional legislation should not contain narrow restrictions or rigid definitions of scope of practice which are excessively exclusive; that measures should be taken (as indicated below) to reduce the area of interprofessional strain and conflict; and that no prosecutions for violations of scope of practice legislation should be undertaken without the prior consent of the appropriate public authority. Insofar as may be possible with due regard for public safety, professional law should not place rigid restrictions on the scope of practice of allied health personnel, and greater flexibility should be encouraged in the allocation of roles between the health disciplines.

(Professor J.T. McLeod, Public Regulation of the Professions in Health Security for British Columbians, Special Report: Consumer Participation, Regulation of the Professions, and Decentralization (1974), the report of Richard G. Foulkes, B.A., M.D., F.A.P.H.A. to the Minister of Health, Province of British Columbia, Tome Three, p. 145)

Thus, the trend in regulatory policy for the health professions has been towards reducing exclusivity in order to enhance interdisciplinary practice, improve accessibility to health care services and increase consumer choice, while at the same time maintaining the fundamental objective of protecting the public.

These policy trends are clearly reflected in the Terms of Reference for the scope of practice review which provide the basis for a new regulatory framework for health professions in British Columbia. The core elements of the new framework are scope of practice statements and reserved acts.

Under the present system, scope of practice statements are exclusive. In the new system, scope statements will not be exclusive but professions may be granted reserved acts.

Reserved acts are those elements of a profession's scope of practice which present such a significant risk of harm that they should be reserved to a particular profession, or shared amongst particular professions. Thus, unlike the present system in which each profession is granted exclusivity within its entire defined scope of practice (subject to specified exceptions), only those acts which present a significant risk of harm will be reserved.

In short, the government has assigned the Council the task of creating a regulatory model based on broad, non-exclusive scope of practice statements and narrowly defined reserved acts.

The government has the responsibility to ensure that those services which are accessible are safe and that the regulatory framework for the practice of health professions protects the public from incompetent, impaired, or unethical practitioners. At the same time, the regulatory framework should not entrench a paternalistic function for professions or reserve exclusive areas of practice simply to enhance professional status and control.

The new system of overlapping scopes of practice and narrow reserved acts removes barriers to interdisciplinary practice and offers greater choice and accessibility to the public. In the Council's view, the public interest is served by professional legislation which promotes quality in the delivery of health care services within safe parameters. Indeed, the Council's primary policy objective in conducting its review is achieving the optimum balance between safe practice and consumer choice.

With this policy background in mind, the Council proposes to consider the practice of nursing by RNs having regard to the four elements of the scope review.

III. DISCUSSION OF ISSUES

The main issues raised by this review are the four elements listed above: scope of practice statement, reserved acts, supervised acts and reserved titles.

A. SCOPE OF PRACTICE

The scope of practice statement describes what the profession does, the methods it uses, and the purpose for which it does it. Unlike the present regulatory system, the statement itself does not grant an exclusive scope of practice. Nonetheless, the statement is important because: it defines the area of practice for which the governing body must establish registration requirements and standards of practice; it defines the parameters of the profession for members of the profession, employers, courts and educators; and it informs the public about the services practitioners are qualified to perform. It is expected that the Council's recommendations will increase overlapping scopes of practice.

The Council believes that it is not necessary or useful to itemize every facet of a profession's scope of practice. Rather, a scope of practice definition should be sufficiently descriptive so that other health professions and members of the public alike can understand what the particular health professional does.

1. Current Scope of Practice of Nursing by Registered Nurses

The existing scope of practice of nursing by RNs is set out in the rules under the Nurses (Registered) Act , RSBC 1996, c. 336 (NRA):

the practice of nursing means the performance for others of health care services which require the application of professional nursing knowledge and skills and includes

a) promoting, maintaining or restoring the health of the general public,

b) teaching nursing theory or practice,

c) counselling persons in respect of health care,

d) coordinating health care services, and

e) engaging in administration, supervision, education, consultation, teaching or research for any of the foregoing.

2. Proposed Scope of Practice

The RNABC initially proposed to maintain the existing scope of practice under the NRA. In the March 1999 joint submission by the BCNU and the RNABC, however, the two groups propose the following revision of the scope of practice statement:

The practice of registered nursing means the performance for others of health services for the purposes of health promotion, maintenance, restoration, or palliation and illness or injury prevention , which require the application of professional nursing knowledge, judgment and skills, and includes:

(a) assessing health status, making a diagnosis, planning and implementing interventions, including care, counselling and advocacy and evaluating outcomes ;

(b) co-ordinating health services; and

(c) engaging in administration, supervision, education, consultation, teaching or research for any of the foregoing.

Words added to the current scope of practice statement of RNs are underlined.

The BCNU and the RNABC state that the wide range of health services makes it impossible to list every type of function RNs perform. They further state that the proposed amended definition removes ambiguity from the current definition and is sufficiently broad to include areas of practice other than direct patient care.

3. Regulation of Registered Nursing in Other Provinces

The Council reviewed the scope of practice definitions in other provinces.

In Ontario, the nursing profession is governed by both the Regulated Health Professions Act, SO 1991, c.18 and the Nursing Act, SO 1991, c.32. The Nursing Act outlines the nurses' scope of practice as follows:

3. - The practice of nursing is the promotion of health and the assessment of, the provision of care for and the treatment of health conditions by supportive, preventive, therapeutic, palliative and rehabilitative means in order to attain or maintain optimal function.

Although Ontario has two classes of membership - registered nurses and practical nurses - all nurses are regulated through the College of Nurses of Ontario, and the scope of practice statement applies to both.

In New Brunswick, two regulated health professions provide nursing services: registered nurses and registered nursing assistants. The scope of practice for nursing is defined in An Act Respecting the Nurses Association of New Brunswick, as follows:

"nursing" means the practice of nursing and includes the nursing assessment and treatment of human responses to actual or potential health problems and the nursing supervision thereof;

Quebec maintains two nursing categories: registered nursing and practical nursing. The Quebec Nurses Act, LRQ, c.I-8, contains a broad definition of nursing in section 36, and a prohibition against practising nursing without a license in section 41. Section 36 states:

Every act the object of which is to identify the health needs of persons, contribute to methods of diagnosis, provide and control the nursing care required for the promotion of health, prevention of illness, treatment and rehabilitation, and to provide care according to a medical prescription constitutes the profession of nursing.

Alberta maintains three categories of nurses: registered nurses, psychiatric nurses, and licensed practical nurses. The latter two are regulated under the Health Disciplines Act, RSA 1980, c. H-3.5. The practice of registered nursing is defined in the Nursing Profession Act, SA 1983, c. N-14.5, as follows:

A registered nurse and a certified graduate nurse are entitled to apply professional nursing knowledge for the purpose of

1. promoting, maintaining or restoring health;

2. preventing illness, injury or disability;

3. caring for the injured, disabled or incapacitated;

4. assisting in childbirth;

5. teaching nursing theory or practice;

6. caring for the dying;

7. co-ordinating health care;

8. engaging in the administration, education, teaching or research required to implement or complement exclusive nursing practice or all or any of the matters referred to in clauses (a) to (g).

In Saskatchewan, registered nurses are regulated under the Registered Nurses Act, SS 1988-89, c.R-12.2, which defines the practice of registered nursing as follows:

"practice of nursing" means the performance or co-ordination of health care services including but not limited to:

1. observing and assessing the health status of clients and planning, implementing and evaluating nursing care; and

2. the counselling, teaching, supervision, administration and research that is required to implement or complement health care services;

   for the purpose of promoting, maintaining or restoring health, preventing illness and alleviating suffering where the performance or co-ordination of those services requires:

3. the knowledge, skill or judgment of a person who qualifies for registration pursuant to section 19 or 20;

4. specialized knowledge of nursing theory other than that mentioned in subclause (iii);

5. skill or judgment acquired through nursing practice other than that mentioned in subclause (iii); or

6. other knowledge of biological, physical, behavioural, psychological and sociological sciences that is relevant to the knowledge, skill or judgment described in subclause (iii).

Finally, Manitoba also has the three nursing categories of registered nurses, registered psychiatric nurses and licensed practical nurses. The Manitoba Registered Nurses Act, RSM 1987, c. R40, defines the scope of practice of RNs as follows:

"nursing practice" or "the practice of nursing" means representing oneself as a registered nurse while carrying out the practice of those functions which, directly or indirectly in collaboration with a client and with other health workers, have as their objective, promotion of health, prevention of illness, alleviation of suffering, restoration of health and maximum development of health potential and without restricting the generality of the foregoing includes

1. collecting data relating to the health status of an individual or groups of individuals,

2. interpreting data and identifying health problems,

3. setting care goals,

4. determining nursing approaches,

5. implementing care, supportive or restorative of life and wellbeing,

6. implementing care relevant to medical treatment,

7. assessing outcomes, and

8. revising plans.

4. Responses to Original Consultation

Many groups responded to the scope of practice initially proposed by the RNABC in June 1995. A subsequent joint submission of the RNABC and the BCNU in March 1999 has revised much of that submission. However, the scope statement proposed in the initial submission is similar to the revised scope statement. Therefore, the initial responses are summarized below.

The British Columbia Association of Podiatrists (BCAP) agreed with the proposal and stated that the scope definition must reflect the fact that nursing is a generalist field which cannot be easily reduced to defined barriers.

The College of Psychologists of BC (CPBC) supported the proposal with the addition of a requirement that all duties be carried out under the direction of a physician. It further stated that exemptions from exclusive scopes of practice or reserved acts of other professions, which was part of the RNs' original submission, should be specified and detailed and then submitted to the concerned health professions for comment.

Several respondents believed the current definition to be too general. For example, the College of Midwives of BC (CMBC) stated that the definition does not enable the public to determine the boundaries of what RNs do. The CMBC recognized that defining the scope of nursing by RNs is difficult as the scope of practice is broad, but it believed the public requires such a definition. The College of Massage Therapy of BC (CMTBC) made a similar submission, as did the College of Physicians and Surgeons of BC (CPSBC), the British Columbia Society of Massage Therapy (BCSMT), and the British Columbia Health Association (BCHA).

Other respondents, representing educators, made the general point that the scope of practice statements for the three nursing professions must reflect the unique characteristics of each profession.

Douglas College stated that there is little differentiation between the three nursing bodies' proposals. Similarly, the Ministry of Education, Skills and Training (MEST) stated that it is difficult to differentiate the three nursing professions, and thus difficult to assess what educational preparation is required.

Finally, Manitoba Health stated that the scope statements for the three nursing professions should follow a similar format.

5. Responses to the Joint Submission of the BCNU and the RNABC

Many respondents approve of the scope of practice statement proposed by the BCNU and RNABC on March 3, 1999.

The College of Licensed Practical Nurses of BC (CLPNBC) states that it has no concern but adds that the proposed scope of practice could apply almost equally to LPNs since they perform a significant part of the RNs' proposed scope of practice. The CLPNBC also states that the proposed scope of practice illustrates the difficulty of establishing different scope of practice statements for RNs, RPNs and LPNs.

The Licensed Practical Nurses Association of BC (LPNABC) finds the proposed scope of practice appropriate and adds that the definition of the practice of "nursing" could serve as the definition for all three disciplines of nursing.

The Hospital Employees' Union (HEU) supports the proposed scope of practice statement and adds that it parallels the role statement for LPNs.

The BC Dietitians' and Nutritionists' Association (BCDNA) supports the amended definition of nursing practice and states that it reflects what nurses currently do.

The Capital Health Region concurs with the proposed scope submission and states that it accurately reflects the anticipated health needs of the population.

University of Victoria, School of Nursing (UVIC) believes the proposed scope of practice statement is clear and incorporates all the essentials of the profession's scope in a succinct manner.

Vancouver Community College (VCC) believes the revised scope of practice will not have an impact on the education of practical nurses.

Some respondents disagree with the proposed scope of practice.

The BC Medical Association (BCMA) states that the inclusion of "making a diagnosis" is inappropriate. It states that the responsibility of making a diagnosis is one of the most important requirements of fitness to acquire a license to practise medicine, and that RNs do not have the necessary training and education.

The BC Psychological Association (BCPA) disagrees with the proposed scope of practice statement and finds it overly broad. Specifically, it states that mental illness and neuropsychology are areas in which RNs lack preparation, and therefore should not be included within their scope of practice.

The BC Association of Podiatrists (BCAP) submits that RNs do not have the extensive and specialized knowledge to make most podiatric diagnoses.

Castlegar and District Hospital (Castlegar) states that the proposed scope of practice appears to broaden the scope to the point of recognizing all nurses as practitioners who will act in an independent and autonomous manner. Castlegar questions who will be in charge of patient care, a responsibility currently resting with the physician.

6. The Council's Conclusions

The Council has carefully reviewed the revised proposed scope of practice statement. The Council agrees with the BCNU and the RNABC that the practice of nursing by RNs requires a broad and general scope of practice statement to reflect the breadth of practice by the profession. However, several portions of the proposed definition are unnecessary in the legislative context. The phrase "which require the application of professional nursing knowledge" does not add to the definition. Item (c), "engaging in administration, supervision, education, consultation, teaching or research for any of the foregoing", encompasses activities which implicitly fall within the scope of practice of all professions, and have not been included in other scope of practice statements.

Finally, the issue of diagnosis, which was proposed by the RNs, and addressed by the BC Psychological Association (BCPA), the BC Association of Podiatrists (BCAP) and the BC Medical Association (BCMA), will be dealt with under the reserved acts section of this report.

B. RESERVED ACTS

The rationale underlying the granting of reserved acts is to protect the public by limiting provision of those particularly dangerous acts to members of specific professions who are qualified to perform them. Only those acts which present a significant risk of harm will be reserved. The Council developed a list of reserved acts, and included it in a 1998 report, entitled the Shared Scope of Practice Model Working Paper (Working Paper).

The list is the Council's working list of activities which present such a significant risk of harm that they should be reserved to regulated health professionals. The list has been revised during the course of the Council's review process. The latest version is attached as Appendix B to this report.

The Council's review will determine which parts of the list will be granted to each profession.

1. Proposed Reserved Acts

In its original submission, the RNABC contended that it is not possible to create a list of reserved acts to capture the full range of nursing practice. It took the position that rather than proposing specific reserved acts, it should receive an exemption from the reserved acts of other professions. In short, the RNABC proposed an expanded scope of practice through exemptions from other professions' reserved acts.

Many of the respondents to the initial consultation criticized this submission, and submitted that it amounted to a request that RNs be granted the same scope of practice as physicians. Those responses will not be reviewed as the RNABC has revised its position.

In the joint submission by the BCNU and the RNABC, the following reserved acts are proposed for RNs:

1. Making a diagnosis, identifying a disease, disorder or condition as the cause of signs or symptoms of the individual.
2. Performing the following physically invasive or physically manipulative acts:
1. procedures on tissue below the dermis, below the surface of a mucous membrane, and in the surface of the cornea;
2. setting or casting a simple fracture of a bone or reducing a dislocation of a joint;

3. administering a substance by injection, inhalation, instillation or irrigation ;
4. putting an instrument, hand or finger(s)
1. into the external ear canal, up to the eardrum,
2. beyond the point in the nasal passages where they normally narrow,
3. beyond the pharynx,
4. beyond the opening of the urethra,
5. beyond the labia majora,
6. beyond the anal verge, or
7. into an artificial opening into the body;

and the maintenance or removal of instruments .

3. Managing labour and conducting vaginal delivery of a baby within an institutional setting .
4. Applying or ordering the application of a hazardous form of energy including diagnostic ultrasound, electricity, magnetic resonance imaging, lithotripsy, laser and x-ray.
5. Prescribing, compounding, dispensing or administering by any means a drug listed in Schedule A-1 or A-3.2 of the Pharmacists, Pharmacy Operations and Drug Scheduling Act.
6. Administering and monitoring initial doses of listed drugs for unstable clients or those with unpredictable outcomes .

Words added to the Council's reserved acts list are underlined.

The BCNU and the RNABC state that RNs already competently and independently carry out most of the activities in the Council's reserved acts list. They are performed either in cases where a patient's medical needs are urgent and a physician is unavailable, or in accordance with institutional protocols or physician orders. The RNABC and the BCNU cite the following activities that RNs currently perform:

• initiate oxygen when required by clients in respiratory distress;

• irrigate blocked intravenous catheters by injecting normal saline;
• select the type of solutions and dressings to use in wound care;
• manage normal labour and delivery;
• remove endotracheal tubes that are blocked;
• adjust respirator settings and/or increase sedative medication for patients on respirators demonstrating symptoms of inadequate ventilation;
• insert urinary catheters for post operative patients who are unable to void;
• determine when and how much of a prescription medication to give to a client; and
• titrate insulin doses for diabetic patients.

The RNABC and the BCNU state that RNs often carry out these activities even though they are currently prevented from doing so by legislative and administrative barriers. They state that RNs, after intervening on a client's behalf, advise the physician of what they have done to obtain the currently required order so as to appear that they did not breach institutional and legislative requirements. Further, the RNABC and the BCNU suggest that delegating medical functions to RNs is another mechanism to circumvent legal rigidities in order to meet client needs in a timely fashion.

They state that RNs' competence to carry out these activities is gained in various ways, including through basic nursing education programs, or through on-the-job experience or post-graduate education. The RNABC and the BCNU also state that the RNABC is prepared to develop additional regulatory mechanisms to ensure that only competent RNs perform a particular reserved act. The mechanisms proposed would be developed after a wide consultation with key stakeholders and would involve self-assessment and formal assessment procedures.

The Council accepts that RNs have the core competency (acquired through basic nursing education) to perform many of services on the Council's reserved acts list in a variety of settings, frequently with little supervision. However, there is an important distinction between competency to perform a reserved act and competency to initiate a reserved act. As the RNABC stated in an August 7, 1998 letter to the Council regarding licensed practical nursing:

It is our understanding the Health Professions Council intends that when a reserved act is assigned to a specific profession, members of the profession have the authority both to (1) make the decision that the act is required and (2) carry out the act.

Thus the general concept of reserved acts is that once granted, the profession initiates and performs the act independently.

The RNABC appears to recognize this distinction in its Guidelines for Specialized Nursing Skills and Delegated Medical Functions. The guidelines distinguish between "basic nursing skills" and "specialized nursing skills". The former are acquired through a basic nursing education program while the latter require post-basic nursing education or inservice programs and work experience. In the same guidelines, the RNs also recognize that they perform medical functions upon delegation.

Nursing is a unique profession because while much of its practice can be considered independent, it is generally carried out as part of a health care team. Nurses are often given the discretion to decide when to initiate a procedure, usually through a physician's order.

Physicians frequently provide orders and rely on nursing professionals to determine when and how they will be carried out. The process of granting discretion to determine when to initiate and perform an act is best described as "performing an act under the order of another profession." Generally, the ability to perform such acts is within the core competency of RNs.

This process is different from the concept set out in the Council's delegation guidelines. Those guidelines contemplate that the delegation will be structured, including some indication of how the delegated act will be performed. It would generally apply when an act is an advanced or specialist practice which does not fall within the core competency of RNs.

To summarize, when a reserved act is performed pursuant to an order, nurses may make the decision to initiate the act, within the parameters of the order, and they are competent to perform it independently. In contrast, with delegation, nurses will be instructed when to initiate the task, and generally speaking, that task would not fall within the core competency of the nursing profession.

Finally, there are some instances in which RNs will independently initiate and perform a reserved act.

The Council will deal with each proposed reserved act in turn, having regard to these preliminary remarks.

a. Making a Diagnosis

This proposed reserved act on diagnosis is identical to the Council's reserved act #1. The BCNU and the RNABC state the following:

When a registered nurse makes a diagnosis, the nurse determines the nature, cause or manifestation of a client's condition based on an assessment of the information obtained from the individual's history, the findings or a comprehensive health examination and, where necessary, laboratory or diagnostic tests, or other examinations.

The BCNU and the RNABC further state that the traditional distinction between medical diagnosis and "other" or nursing diagnosis is unnecessary. They add that diagnosis falls within the current and proposed scope of practice of RNs. More importantly, the RNABC and the BCNU contend that if granted this reserved act, RNs must be able to order the tests necessary to undertake differential diagnosis and necessary, subsequent treatment. Finally, the RNABC and the BCNU argue that RNs must also have access to the laboratory and diagnostic facilities where tests are performed. They state that there should be no artificial barriers that prevent laboratory physicians from accepting referrals or requests for laboratory tests from RNs.

With respect to RNs' competence to make diagnoses, the RNABC and the BCNU state that they develop their competence like physicians, by a combination of academic education and hands-on experience, which includes:

• comprehensive health assessment techniques for all developmental stages, using a systems-based approach and including history taking and physical assessment and the use of an appropriate range of diagnostic tests and screening tools to determine the health status of clients across the life span;
• critical thinking and diagnostic reasoning skills in assessing, diagnosing and managing the care of clients in all health care settings; and
• knowledge of the pathophysiology of acute and chronic illnesses and injuries.

Further, the RNABC and the BCNU state that RNs presently independently diagnose a client's condition in a variety of settings, such as:

• community health RNs diagnosing communicable diseases such as chicken pox and measles;
• RNs in acute and long-term facilities diagnosing atrial fibrillation, fetal distress, venous stasis ulcer, hypo/hyperglycemia, myocardial infarction, fractured hip and renal colic; and
• RNs in a number of settings (e.g. Medical Services Branch Nursing Station Facilities or hospital emergency rooms) diagnosing allergies and allergic reactions, dental problems, respiratory conditions, hemorrhage, thermal injuries, and seizure disorders including febrile convulsions.

The RNABC and the BCNU stress that RNs must be aware of their limitations in making a full and accurate diagnosis, and if a situation exists that is beyond an RN's competence, then the RN either consults with or refers the patient to another health care practitioner such as a physician.

The Capital Health Region agrees with the rationale for the reserved act on diagnosis and states that diagnosis is an essential component of independent practice of RNs and a reality in many regions of BC.

University of Victoria School of Nursing (UVIC) stresses that it fully agrees that RNs be granted the reserved act of diagnosis and thereby put an end to semantic variations of the term diagnosis in an attempt to stay within the current nursing scope of practice.

The Licensed Practical Nurses Association of BC (LPNABC) questions the competence of RNs to perform diagnosis.

The BC Psychological Association (BCPA) states that if RNs are granted the reserved act of diagnosis, a qualifying statement should be added so that diagnosis of mental illness is excluded. The BCPA states that RNs lack the competency to diagnose or treat mental illness.

With respect to the request that RNs be allowed to order tests to undertake differential diagnosis, Castlegar and District Hospital (Castlegar) states this reflects a "physician assistant" role which goes beyond current training levels of educational institutions and would lengthen the training course.

The BC Medical Association (BCMA) submits that "the [RNs'] statement that a diagnosis is a diagnosis no matter what profession is performing the function is unsubstantiated." With respect to the claim that no artificial barrier be created to prevent laboratory physicians from accepting referrals for laboratory tests from RNs, the BCMA states that such referrals and requests are accepted from no group that has not given proof of adequate education and training in the selection and interpretation of tests. The BCMA states that it is essential that tests are ordered only by persons with fundamental training and background as a diagnostician. Also, the BCMA states that the final statement regarding the limitations in ability to make a full and accurate diagnosis betrays the necessity for proper and extensive education and training prior to accepting responsibility for making a diagnosis. In short, the BCMA submits that RNs are not trained or educated to perform diagnosis.

Finally, the BC Association of Podiatrists (BCAP) and the Board of Examiners in Podiatry (BOEP) state that diagnosis should be restricted to situations where a doctor is not reasonably available.

In its Working Paper the Council stated:

The Council believes it important to distinguish between diagnosis and assessment. Essentially, diagnosis is the identification of the cause of signs or symptoms. Assessment is a process of observation and evaluation of the physical status or progress of a patient, which may involve observation of symptoms, but does not include naming or identifying a disease, disorder, or condition as the cause of these symptoms.

In the Council's view, all health care practitioners assess a client's progress and response to services rendered. Practitioners who offer assessments have provided information to the Council on this issue, either in recent applications for designation or in submissions in the scope of practice review. Such practitioners include: counsellors, rehabilitation practitioners, prosthetists and orthotists, athletic trainers and recreation therapists.

In the Council's view, it is the identification of a disease, disorder or condition as the cause of signs or symptoms of the individual which should be a reserved act, and the process of assessment should continue to be in the public domain. Both regulated and unregulated practitioners would be free to perform assessments during the course of providing health care services, subject always to the proposed general risk of harm clause.

Thus, there is a distinction between diagnosis and assessment.

The services described in the joint submission constitute assessment, not diagnosis and therefore this reserved act should not to be granted to RNs. To the extent that certain groups of nursing professionals, such as out-post nurses, provide diagnostic services, the issue can be addressed through the Council's delegation guidelines.

b. Physically Invasive or Manipulative Procedures

(1) Procedures on tissue below the dermis

The RNABC and the BCNU state that RNs commonly and independently perform the wound and skin management care that falls within this reserved act, and the following specific activities:

• Insertion of an intravenous catheter;
• Venipuncture and arterial puncture to obtain blood specimen;
• Wound debridement, irrigation or packing; and
• Wound suturing or removal of suture.

The BC Association of Podiatrists (BCAP) and the Board of Examiners in Podiatry (BOEP) state that procedures below the dermis should be more clearly defined to avoid giving RNs the licence to use this reserved act to perform surgery.

The BC Medical Association (BCMA) questions whether nurses have the education and training necessary to determine when these acts ought to be initiated.

The Council accepts that the performance of these services falls within the core competency of RNs.

(2) Procedures in the surface of the cornea

The RNABC and the BCNU state that although RNs do not currently perform procedures below the surface of the cornea, they perform procedures on , or in the surface of the cornea, in many situations and that nurses have the required competency to be able to perform this act.

The Council accepts that the performance of these services falls within the core competency of RNs.

(3) Setting or casting a simple fracture of a bone or reducing a dislocation of a joint

The BCNU and the RNABC propose to narrow the Council's reserved act by adding the word "simple" to exclude complex or compound fractures. The RNABC and the BCNU believe that the latter type of fractures require medical expertise. They also state that RNs do not carry out these activities unless they have received additional, or on-the-job training and education. The RNABC indicates its readiness to develop additional regulatory mechanisms to ensure competency for this reserved act.

Further, the RNABC and the BCNU state that the narrower act of setting or casting "simple" fractures is usually performed by RNs through medical protocols. However, the RNABC and the BCNU also indicate that RNs, while under the direction of a physician's order, usually make the initial diagnosis, immobilize or cast a simple fracture, or reduce a dislocated joint.

The BC Association of Podiatrists (BCAP) and the Board of Examiners in Podiatry (BOEP) comment that setting and casting a simple fracture should not be interpreted to allow RNs to treat podiatric fractures as they are not trained or educated to perform this service.

The BC Medical Association (BCMA) states this act is requested without any reference to the RNs' education and competence in the ordering and reading of x-rays.

The Council accepts that nurses sometimes perform such services but they are not part of the core competency of RNs.

(4) Administering a substance by injection or inhalation, instillation or irrigation

The Council's reserved act #2(d) presently reserves "administering a substance by injection, inhalation, or instillation through enteral or parenteral means".

The BCNU and the RNABC interpret this reserved act to include the administration of substances such as intravenous fluids, oxygen and gases that do not qualify as listed drugs under the Council's reserved act #5, prescribing, compounding, dispensing or administering a drug. The RNABC and the BCNU state that RNs routinely administer intravenous fluids, oxygen and gases such as entonox and nitrous oxide.

Further, the RNABC and the BCNU have added the words, "instillation or irrigation" because these procedures carry potential risk of harm to the public:

For example, irrigation can result in dislodgment of a venous or arterial clot, rupture of a urinary catheter, or dislodgment of a shunt or drain in an operative site.

The College of Licensed Practical Nurses of BC (CLPNBC) agrees with the joint submission that the act of instillation and irrigation be added to the Council's list of reserved acts.

As a result of the report on the designation of dietetics and nutrition, the Council has added "instillation" to the list of reserved acts. The Council also agrees that irrigation presents a significant risk of harm, and has added it to the Council's list of reserved acts.

The Council accepts that the performance of these services falls within the core competency of RNs.

(5) Physically invasive or manipulative acts of putting an instrument, hand or finger(s) into orifices of the body

(i) putting an instrument, hand or finger(s) into the external ear canal, up to the eardrum

The BCNU and the RNABC agree with the BC Association of Speech/Language Pathologists and Audiologists that the reserved act of "putting an instrument, hand or finger(s) beyond the external ear canal" should state " into the external ear canal...". The Council agrees and has amended the reserved acts list. The RNABC and the BCNU state that this reserved act is initiated and performed by RNs without an order from a physician or other health care practitioner.

The RNABC and the BCNU state in their joint submission:

Registered nurses commonly use an otoscope to assess the inner ear and remove cerumen with an ear syringe inserted into the external ear canal. As with previous examples, registered nurses initiate these procedures and are capable of doing so without an order from a physician or other health care practitioner.

The Licensed Practical Nurses Association of BC (LPNABC) argues that all reserved acts of performing physically invasive and physically manipulative acts should be granted to RNs and also to LPNs.

The BC Association of Podiatrists (BCAP) and the Board of Examiners in Podiatry (BOEP) see this part of the request as another broad definition with the potential to allow RNs to perform surgery.

The performance of these acts for the most part falls within the core competency of RNs. However, the Council is of the view that cerumen management requires advanced certification including formal training and education, and therefore, does not fall within the core competency of RNs.

(ii) putting an instrument, hand or finger(s)
• beyond the point in the nasal passages where they normally narrow,
• beyond the pharynx, and
• into an artificial opening into the body

The RNABC and the BCNU state that RNs insert naso-gastric tubes for purposes of feeding, aspiration or lavage. RNs also perform oropharyngeal suctioning to assist stroke or frail patients to clear chest secretions. Finally, the RNABC and the BCNU state that RNs perform ostomy irrigation, change tracheostomy tubes and change gastronomy buttons and tubes.

The RNABC and the BCNU state that the reserved acts are carried out in completing physicians' orders. However, they state that RNs are competent to independently assess and initiate these procedures.

The Council accepts that these services fall within the core competency of RNs.

(iii) putting an instrument, hand or finger(s)
• beyond the opening of the urethra and
• beyond the anal verge

With regard to the above reserved acts the BCNU and the RNABC state that both are carried out with or without a physician's order, and where a physician's order exists, it is so broadly stated that full authority to determine the need and performance of the procedure is effectively delegated to the RNs.

The Council accepts that the performance of these services falls within the core competency of RNs.

(iv) putting an instrument, hand or finger(s) beyond the labia majora

The RNABC and the BCNU state that the above reserved act is within RNs' current scope of practice and can be performed independently by them. They cite several examples where RNs currently perform this reserved act, including insertion of a speculum to obtain a pap smear, or a swab for obtaining a vaginal or cervical specimen, or forensic specimens subsequent to a sexual assault; insertion of fingers beyond the labia majora to determine cervical dilatation; and insertion of intrauterine devices or a dispenser for purposes of administering medication.

The Council accepts that the performance of these services falls within the core competency of RNs, except with respect to the insertion of intrauterine devices.

(v) maintenance or removal of instruments

Finally, the RNABC and the BCNU also ask that the reserved act of putting an instrument, hand or finger(s) into orifices of the body be clarified to define the word instrument and that RNs be granted the reserved act of maintaining and removing the instruments. The RNABC and the BCNU believe that the maintenance or removal of instruments presents a significant risk of harm that is separate from the act of putting an instrument, hand or finger(s) into body orifices.

Such services do not warrant inclusion on the Council's reserved acts list as they are essential safety services provided by virtually all health professions in the course of their practice, and no independent risk of harm has been established.

c. Managing Labour and Conducting Vaginal Delivery of a Baby Within an Institutional Setting

The BCNU and the RNABC state that this act falls within RNs' current scope of practice. The RNABC and the BCNU clarify that though derived from a delegated medical function, the delegation for this reserved act is so open ended that RNs essentially make independent decisions. The Council notes that the proposed reserved act is limited to "vaginal delivery of a baby" and "within an institutional setting". The BCNU and the RNABC propose this narrowed act due in part to the reserved acts granted to midwives and to their view that an apparently uncomplicated labour and delivery can change and require immediate medical intervention. The RNABC indicates its readiness to implement additional regulatory mechanisms to ensure competence if granted the reserved act.

The Midwives Association of BC (MABC) and the College of Midwives of BC (CMBC) strongly oppose the RNs' request for this reserved act.

They state that the scope expansion undermines the safety, security, comfort and faith of birthing women, and is unnecessary in light of emerging professional midwifery services in BC. They oppose the proposal of the RNs to redefine their scope of practice to include managing labour and conducting vaginal delivery. They believe the requested act is a departure from the current nursing mandate insofar as it enables RNs to independently perform health services for which they currently must seek permission and direction from a physician. The MABC and the CMBC further state that the RNs' request to entrench a more specific version of current reserved acts does not serve the needs of BC women and their families, and undermines the emerging role of professional midwives. Further, the MABC and the CMBC contend that neither nursing education nor on-the-job experience prepares RNs to manage labour and delivery from a primary care perspective.

With respect to demonstrating competency, the MABC and the CMBC argue that the RNABC and the BCNU have neither the mandate nor jurisdiction to determine if their members are competent to provide primary care for labour and delivery. With the establishment of the MABC and the CMBC, there are now established formal standards by which midwives must be evaluated. These standards have been set to protect the public and ensure a high quality of care for BC women. The MABC and the CMBC contend that less stringent assessments should not be allowed to diminish birthing women's confidence in the safety and competence of their care providers. Further, the MABC and the CMBC state that the RNABC and the BCNU have not suggested any concrete methods for formal assessment of competence of their members.

The MABC and the CMBC ask the Council to examine proposed changes to the scope of practice for RNs regarding managing labour and vaginal delivery in the context of the Council's own comments in its Working Paper.

The Midwifery Task Force of BC (MTFBC) states it is inappropriate to include normal vaginal delivery in the RNs' scope of practice without first demonstrating there would be significant improvement in the care for birthing women. It also states that the RNABC/BCNU proposal to allow RNs to manage normal labour delivery contradicts the RNABC's previous support and recommendation for the integration of midwifery services. Specifically, it contradicts an RNABC statement supporting a model of maternity care where continuity of care exists. Further, the MTFBC states that if nurses were permitted to conduct normal vaginal delivers in hospitals, it foresees a future where such hospitals would be even less likely to grant privileges to registered midwives than they presently do.

With regard to the claim that RNs already "conduct normal deliveries as a delegated medical function", the MTFBC states that it has seen no documentation supporting the statement, and if nurses are indeed conducting vaginal deliveries on a regular basis, there is currently no structure in place to assess their competency to do so. In sum, the MTFBC states that RNs who wish to conduct normal vaginal deliveries must first be required to undertake extensive training, similar to the training required for midwives, in order to provide for public safety.

The BC Medical Association (BCMA) does not support this request and states that the accuracy of the self-reported assessment and the actual rate of registered nurse-managed deliveries need to be verified.

The Council does not doubt that RNs are involved in various aspects of managing and conducting delivery. However, such RNs specialize in this practice area, and the Council does not accept that these services fall within the core competency of RNs.

d. Applying or Ordering the Application of a Hazardous Form of Energy

The RNABC and the BCNU identify several forms of hazardous energy that RNs commonly apply or order independently: bilirubin lights for neonates or x-rays for diagnostic purposes, defibrillation, cooling/heating blankets and external pacemakers. The RNABC and the BCNU explain that in some situations, both the authority to order and apply are required such as with defibrillation, cooling/heating blankets and external pacemakers.

The BC Association of Medical Radiation Technologists (BCAMRT) is opposed to RNs performing this reserved act. It believes that these procedures should be ordered by a physician as they are highly sophisticated examinations and require expertise beyond that of a registered nurse. The BCAMRT agrees that in special circumstances where a physician is unavailable a registered nurse should be allowed to proceed with the order of basic x-rays to expedite the speedy treatment of the patient. It also questions the ability of the registered nurse to correctly interpret x-rays.

The BC Medical Association (BCMA) states that the RNs did not supply information about adequate theoretical and practical education regarding this reserved act.

The Council does not accept that these services fall within the core competency of RNs.

e. Prescribing, Compounding, Dispensing or Administering a Listed Drug

The RNABC and the BCNU adopt the definitions found in the Council's reserved acts list for this reserved act. They state that RNs commonly prescribe medications under the authority of medical protocols in different settings, such as in rural communities where physicians are unavailable, in acute care settings or in community health centres. The RNABC and the BCNU recognize the need for additional education and possible regulatory mechanisms by the RNABC before a RN is granted prescriptive authority.

The RNABC and the BCNU also state that if granted the authority to prescribe drugs, RNs must also be granted the authority to dispense medications. The two groups state a process is currently in place which allows RNs to dispense a defined quantity of medications in emergency or specified conditions, such as when no in-hospital pharmacist and physician is available and no community pharmacy is accessible, or when there is urgency to the dispensing because of the patient's unique needs.

Further, the RNABC and the BCNU state that the act of compounding a drug is carried out by RNs on a daily basis. With regard to administering drugs, the RNABC and the BCNU state that this falls within RNs' current scope of practice and is common to virtually every RNs' practice.

University of Victoria School of Nursing (UVIC) emphasizes that this reserved act be granted to RNs in their role as primary providers of direct care to clients in all settings where health care is delivered, and as the profession in most regular contact with patients.

The College of Licensed Practical Nurses of BC (CLPNBC) requests that this reserved act be carried out by LPNs. It states that LPNs have had the competence to administer drugs since 1984. The CLPNBC clarifies that it is not asking for the reserved act of prescribing or dispensing a drug.

The BC Medical Association (BCMA) is strongly opposed to granting this reserved act to RNs. The BCMA states that this reserved act is the most hazardous of all the acts requested. It states that nurses have not obtained anything approaching the level of knowledge and application of pharmacology and pharmacotherapeutics acquired by a physician. It states that further evidence is needed of the training in the nursing program.

This reserved act is very dangerous. Improper prescription or administration of a drug can have fatal consequences. Further, the incidence of drug related complications is significant.

The Council is not satisfied that this entire reserved act, particularly "prescription", is within RNs' core competency. However, the administration of drugs prescribed by a physician is clearly within the core competency of RNs.

f. Administration of and Monitoring Initial Doses of Drugs for Unstable Clients or Those with Unpredictable Outcomes

The BCNU and the RNABC propose that this reserved act be added to the Council's reserved acts list and be granted to RNs. Further, the two groups offer the following definitions:

For the purpose of this reserved act:

administration" of the initial dose includes the prior assessment of the patient, and giving the listed drug

"monitoring" means evaluating the patient for signs of efficacy or side effects of the administered listed drug; and

"initial dose" means the amount of a listed drug that is to be administered in a period of time defined by the manufacturer's specifications as being sufficient for the efficacy or side effects of the drug to become apparent.

The RNABC and the BCNU state that the intent of this proposed reserved act is to ensure that health providers who are competent to determine the appropriateness of a medication and recognize and deal with potentially negative side effects, in a timely fashion, administer and monitor the initial dose for unstable patients or those with unpredictable outcomes. They state that RNs' education program enables them to look for and recognize negative drug-on-drug or drug-on-patient effects.

This proposed act is already encompassed within the current version of reserved act #5 of the Council's list, "prescribing, compounding, dispensing or administering by any means a [listed drug]".

2. General Comments From Respondents Regarding Proposed Reserved Acts

The College of Licensed Practical Nurses of BC (CLPNBC) generally agrees with the proposed reserved acts for RNs, with the exception of reserved act e), prescribing, compounding, dispensing or administering a listed drug, above. Further, the CLPNBC states that the initiation of reserved acts for nursing should not be done solely by RNs but by all three nursing groups.

The Licensed Practical Nurses Association of BC (LPNABC) finds the proposed reserved acts appropriate but adds that they will limit the current practice of other nursing disciplines, including LPNs. The LPNABC asserts that the self-assessment of competence process described by the RNABC also applies to LPNs as they are expected to recognize the limits of their competence. The LPNABC states it would be counter-productive if the reserved acts proposed by the BCNU and the RNABC are granted solely to RNs. The Health Employees' Union (HEU) echoes the statements of the CLPNBC and the LPNABC and states that all three nursing categories, including LPNs, have the competence to initiate care and services associated with the appropriate reserved acts.

The BC Association of Podiatrists (BCAP) and the Board of Examiners in Podiatry (BOEP) have serious concerns with the revised scope of practice submission, particularly with podiatric nursing care. The BCAP and the BOEP question the claim by the RNABC and the BCNU regarding training and regulatory mechanisms with respect to nursing foot care. The BCAP and the BOEP state they have not been consulted on either issue. Further, they question the reliability of the self-assessment method proposed by the RNABC and the BCNU in the face of increasing "entrepreneurial endeavours" by RNs who provide podiatric care.

Castlegar and District Hospital (Castlegar) states that adding to the scope of reserved acts and then developing additional regulatory mechanisms appears to add red tape and bureaucracy. Generally, it characterizes the proposals as ambitious.

The BC Medical Association (BCMA) states that the RNs must demonstrate competence for all requested reserved acts. It states that it is incumbent upon any profession to develop and define standards of education, training and evaluation prior to seeking the right to expand its scope of practise.

3. The Council's Recommendations

On previous pages the Council discussed the distinction between the delegation of a reserved act and the performance of a reserved act on the order of another health professional. When a reserved act is performed pursuant to an order, nurses may make decisions to initiate the act, within the parameters of the order, and they are competent to perform it independently.

However, several acts performed by nurses, particularly those described by the RNABC and the BCNU as being beyond core competency, are more appropriately dealt with as delegated acts. With delegation, the nurse will be instructed when to initiate the task, and generally speaking, that task would not fall within the core competency of the nursing profession. These acts generally require advanced training and education, and are performed by nurses in specialty practice areas. This process is provided in the Council's delegation guidelines.

The Council has accepted that nurses initiate and perform some of the reserved acts independently, without an order.

Other reserved acts are performed by the RNs but not initiated by them.

Several of the acts listed in the joint submission are not within the core competency of most RNs, require advanced training, and are performed only by RNs practising within specialty areas. These include:

1. Making a diagnosis, identifying a disease, disorder or condition as the cause of signs or symptoms of the individual;

2. Performing the physically invasive or physically manipulative act of setting or casting a simple fracture of a bone or reducing a dislocation of a joint;

3. Managing labour and conducting vaginal delivery of a baby within an institutional setting;

4. Applying or ordering the application of a hazardous form of energy including diagnostic ultrasound, electricity, magnetic resonance imaging, lithotripsy, laser and x-ray;

5. Administering and monitoring initial doses of listed drugs for unstable clients or those with unpredictable outcomes.

Involvement of RNs in these acts is better dealt with through the Council's delegation guidelines.

C.     SUPERVISED ACTS

The RNABC does not identify any specific acts which may be performed by persons supervised by RNs.

The RNABC's position is that creating a list of supervised tasks is not feasible given the broad range of nursing services provided by RNs. The RNABC is of the view that their Guidelines for the Delegation of Nursing Tasks and Procedures are sufficient to allow safe provision of nursing tasks and procedures by persons other than RNs, including LPNs and family members.

The Terms of Reference imply that the Council will, for each reserved act granted to nursing by RNs, determine the circumstances in which the act may be performed by someone other than a member of that profession. The Council considered this issue in detail in its recent preliminary report regarding the scope of practice of medicine. The Council first noted the submissions of the CPSBC:

In its submission, the College makes a compelling argument that legislation is a blunt instrument to deal with this issue. The College states that the issue of delegation and supervision is a question of individual competence and the circumstances of each case, and that supervision of certain acts can be addressed only after a careful review of all the circumstances surrounding a particular act and by imposing, where necessary, clear guidelines, restrictions or conditions on such supervision.

The College further submits that compiling a list of acts which may be delegated or performed under supervision would not adequately address the complexities of medical situations which present to physicians nor would it protect the public. The College notes that there will be situations where, because of the individuals involved, the site or location, or the specific nature of the presenting problem, it may not be appropriate to delegate an act which might otherwise be capable of delegation.

The Council accepted this submission and stated as follows:

The Council accepts much of this submission, and believes that it would be better to take a general approach to the issue of supervision. The general thrust of the approach is that the decision as to whether an act can be performed under supervision should be left up to the health professions, and that a set of principles embodying the duties of the delegating professional and his or her regulatory college be established and enacted into legislation when the shared scope of practice model takes effect. The principles are derived largely from the CMA's Guidelines for the Delegation of a Medical Act which the College enclosed with its submission.

As a result, the Council stated that supervised acts would not be dealt with individually for each profession, and made a general recommendation regarding this issue and stated:

The Council believes this general approach to supervised acts more accurately reflects the reality that procedures to be delegated vary from profession to profession and may include subsets and variations of reserved acts and further, may be performed under a myriad of circumstances and conditions.

In its preliminary report on the scope of practice of medicine the Council also noted the following:

• Although this term of reference refers to "supervised" acts, it is intended to encompass any situation where someone other than the person to whom the reserved act has been granted performs that act. In other words, this term of reference refers to both delegation and supervision.

• This proposal is not intended to apply on a case-by-case basis. The requirement for approval of the governing body is meant to apply generally and not to individual cases, and would be satisfied by, for example, a general protocol in respect of delegation of reserved acts.

This general position should be applied to all professions. The general position is largely a recognition that a regulatory body is in the best position to determine when other health professionals can perform services under supervision, and thus a regulatory body should be charged with determining when delegation is appropriate in accordance with the principles set out above.

The Council wishes to emphasize that the issue of delegation arises only with respect to reserved acts.

D.     RESERVED TITLES

Reserved titles are titles reserved exclusively to a health profession. Reserved titles afford a means for consumers to identify the different types of health care providers, to distinguish the qualified from the unqualified, and to differentiate those practitioners who are regulated from those who are not. Titles must adequately serve the public in describing the practitioner and the services being provided and must distinguish the practitioner from others performing services outside the jurisdiction of the college.

The RNABC proposes to maintain the current titles in the Nurses (Registered) Act (NRA): "Registered Nurse", "R.N.", "Licensed Graduate Nurse", "L.G.N.", and "Nurse". Presently, the generic term "nurse" is granted to registered nurses, registered psychiatric nurses, licensed practical nurses, and Christian Science nurses.

The RNABC states that the licensed graduate nurse (LGN) category was created to "grandfather" in a group of nurses. LGNs are persons who did not meet the requirements for registration as RNs in 1988. They were granted the title licensed graduate nurse, as long as they were employed in a capacity substantially equivalent to an RN and had graduated from a school of nursing that had standards substantially equivalent to those of any approved school of nursing. The RNABC states that the LGN category is now closed and will eventually disappear as individual LGNs leave the profession or become registered.

The BCNU for the most part agrees with the RNABC submission but makes an additional submission about the use of the generic title "nurse". The BCNU states that only RNs and RPNs should be entitled to use the term "nurse", and that LGNs be allowed to use the title only until such time that they are registered under the HPA as RNs.

The BCNU proposes that LPNs, Christian Science nurses, and student nurses not be allowed to use the title. The BCNU submits that LPNs should not call themselves nurses because they do not share the same scope of practice with RPNs, LGNs and RNs, and they receive significantly less training. Removing LPNs' ability to use the title "nurse" would decrease the public confusion which, the BCNU states, now exists. The BCNU also makes reference to the NRA provision allowing for use of the title "nurse" by RNs or RPNs from another jurisdiction who are employed in BC for 30 days or less. The BCNU suggests that the HPA include wording to show that the extra-provincial registrants are not registrants of the RNABC.

With respect to Christian Science nurses the BCNU explains that the Ministry of Health justified the use of the title "nurse" after representatives of Christian Science lobbied the government for it. The BCNU states that no other Canadian jurisdiction has created a similar amendment to its nursing legislation. It asserts that Christian Science nurses' education is different from RNs, LGNs and RPNs, and their knowledge is derived from spiritual rather than from science and empirical health care practice.

Finally, as regards student nurses, the BCNU states that like physicians/surgeons who take their undergraduate medical training and are not permitted to call themselves "doctor", "physician" or "surgeon", student nurses should not be allowed to call themselves "nurse" until they are registered with either the RNABC or the RPNABC.

The College of Licensed Practical Nurses of BC (CLPNBC) agrees with the proposed reserved titles listed in the joint submission. It also states that it cannot understand the BCNU proposal to eliminate the title "nurse" as a reserved title. The Licensed Practical Nurses Association of BC (LPNABC) argues that the title "nurse" should be reserved as per the comments of the RNABC. It strongly disagrees with the contention by the BCNU that the title "nurse" be taken away from LPNs.

The Health Employees' Union (HEU) strongly objects to the BCNU position. It states that LPNs have been an integral part of the nursing profession in BC. It cites the Ontario situation where practical nurses and RNs are regulated by the same body and are authorized to perform the same controlled (i.e., reserved) acts. The HEU states that the competency of BC's LPNs parallel those in Ontario and other provinces.

Many submissions express general support for the RNABC's submission on titles, including the BC Society of Occupational Therapists (BCSOT), the BC Association of Community Care (BCACC), the BC Medical Association (BCMA), the BC Association of Podiatrists (BCAP), the College of Psychologists of BC (CPBC), the Greater Victoria Hospital Society (GVHS) and the Skeena Health Board.

Several submissions, such as the Licensed Practical Nurses Association of BC (LPNABC), the Registered Psychiatric Nurses Association of BC (RPNABC) and Manitoba Health state that the title "nurse" should always be accompanied by a descriptive title, such as "Registered" or "Licensed Practical".

The Health Employers Association of BC (HEABC) indicates that the widespread use of the titles "nurse", may be confusing given that it may be used by nurses with widely varying levels of certification. A similar submission was made by BC Institute of Technology (BCIT), and the Ministry of Education, Skills and Training (MEST).

The Council has carefully considered the BCNU's proposal regarding the title "nurse", and the submissions received. The proposal is a request to change the existing law regarding the use of the title "nurse". The Council's Terms of Reference indicate that the primary criteria for considering reserved titles is whether they adequately serve the public. The Council has not been presented with any significant evidence that the use of the current system for use of the generic term "nurse", which allows RNs, RPNs and LPNs to use the title, has led to any confusion amongst the public.

E.     OTHER ISSUES

1. Name of the Regulatory Body

In British Columbia, the name of the body responsible for regulating nursing by RNs is the "Registered Nurses Association of BC". Generally speaking, it is customary within the health professions to refer to the regulatory body as the "College", while the professional body is identified as the "Association". This is the practice in British Columbia, and most other Canadian jurisdictions. This practice greatly assists the public in determining the respective roles of the two bodies.

2. Abolition of Separate Nursing Categories

The Council notes that various submissions propose that separate nursing categories be abolished by requiring LPNs to upgrade their education and qualify as RNs. Another submission proposes to abolish the profession of registered psychiatric nursing and yet another calls for the elimination of the category of licensed practical nursing. This issue is beyond the Council's mandate for this review and was not addressed by the Council.

3. Nurse Practitioners

The implication of much of the BCNU and RNABC submission is that all members of the RNABC should be entitled to practice as independent nurse practitioners. For example, they state:

Granting registered nurses reserved acts should also improve access to a number of health care services that are currently provided exclusively by physicians. It should reduce health care costs as nurse practitioners are known to assist clients to more effectively manage their own health issues, prescribe fewer medications and other interventions, and focus more on health promotion and illness prevention. [Emphasis added.]

The notion of wholly independent practice by nurses is embodied in the nurse practitioner concept. A nurse practitioner is a professional trained and educated to perform primary health care similar to that provided by medical practitioners.

The Ontario government has created just such an independent class of nursing professionals through legislation. The initiative was preceded by a lengthy review process and in particular, by establishing an appropriate training program. Early in 1994, the Ontario Ministry of Health formally launched a nurse practitioner project to consolidate and acknowledge the role that nurse practitioners had been fulfilling in Ontario for a number of years.

According to the Ontario Minister of Health, nurse practitioners are RNs who have additional nursing education. The Minister proposed amendments in favour of nurse practitioners to a regulation under the Regulated Health Professions Act, SO 1991, c.18 (RHPA) which exempts certain persons from the prohibition against performing controlled acts. This proposed exemption was met with strong opposition leading the Minister to refer the intended amendment to the HPRAC.

In March 1996, the Health Professions Regulatory Advisory Council (HPRAC) of Ontario submitted its report, Advice to the Minister of Health, Nurse Practitioner Referral, to the Minister of Health. The report is a 65-page comprehensive report that deals with the issue of whether nurse practitioners should be authorized to perform certain requested controlled acts.

Of the 13 controlled acts contained in the RHPA, nurse practitioners were granted three, as follows:

• Communicating a diagnosis, subject to the limit that diagnoses can only be communicated which:

  »   are reached through considering the individual's history, the findings of a comprehensive health examination, and where necessary, the results of laboratory tests and other investigations that the member is authorized to order or perform; and

  »   are reached after complying with the mandatory indicators for consultation or referral.

• Ordering a form of energy limited to diagnostic ultrasound, and in principle, the ordering of x-rays, subject to a review of the education program for nurse practitioners.

• Prescribing drugs limited to those designated in the regulations.

In contrast, the vast majority of regular members of the College of Nurses are currently authorized under section 4 of the Nursing Act, SO 1991, c. 32, to perform the following three controlled acts, on the order of a medical practitioner or some other health care professionals:

• Performing a prescribed procedure below the dermis;

• Administering a substance by inhalation or injection; and

• Putting an instrument, hand or finger beyond body orifices.

Nurse practitioners in Ontario are authorized to perform six of the 13 controlled acts, with significant limitations as to the controlled acts of diagnosis, ordering a form of energy, and prescribing drugs. In contrast, the vast majority of RNs perform reserved acts only on the order of a medical practitioner.

In the RNABC and BCNU submission a request is made for six of the seven reserved acts on the Council's list. RNs in BC are asking for more reserved acts than what the nurse practitioners of Ontario were granted. Further, they are requesting that all of its registrants be granted the six requested reserved acts. In contrast, the Ontario nurse practitioner program is limited to a defined class of registrants.

The Council is not suggesting that a nurse practitioner role is unwarranted. On the contrary, the Council concludes that the concept of nurse practitioners is sound, and ought to be explored further by the Minister. This type of review is beyond the Council's mandate for this scope of practice review.

IV. RECOMMENDATIONS