Health Professions Council
POST-HEARING UPDATE OF PRELIMINARY REPORT:
REGISTERED NURSES

The Council issued its Registered Nurses Scope of Practice Review (Preliminary Report) in March 2000. The public hearing was held on 12-13 June 2000. The following are changes to the Preliminary Report which arose from the submissions made either at the public hearing or in subsequent written submissions.

I. SCOPE OF PRACTICE

The Council’s Preliminary Report recommended the following scope of practice 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.

Many participants at the public hearing submitted that the scope of practice statement should refer to "palliation" as it is a significant part of nursing practice. The Registered Nurses Association of British Columbia (RNABC) stated:

(T)he omission of the word palliation is problematic, since no other word in the scope statement describes this important aspect of nursing. Scope of practice statements for registered nurses in other jurisdictions, such as Saskatchewan and Manitoba, make reference to this particular aspect of nursing’s scope of practice. The phrase "promotion, maintenance and restoration of health" does not include the supportive activities that are part palliative care.

The School of Nursing, University of Victoria stated:

The administration of comfort and palliative measures is core to registered nursing practice in virtually every setting. With increased numbers of elders and chronically ill clients, most registered nurses can expect to care for dying people (and their families) regularly. The SOP statement, in requiring nurses to focus only on "promotion, maintenance and restoration of health", ignores the reality of dying and the vital role of nurses in caring for individuals (and their families) at the end of life. If palliation does not fall within nursing’s scope of practice, who will provide nursing care to the dying?

Similar submissions were made to the Council by the Health Employers Association of British Columbia, the Public Health Nursing Leaders Council, the B.C. Cancer Agency, the Children’s & Women’s Health Centre of British Columbia, Providence Health Care, and the Vancouver Hospital and Health Sciences Centre.

The scope of practice statement is not intended to list all the activities a profession performs. It is intended to be succinct and generally to describe what a profession does and how it does it so that other professions and the public will know what to expect from the profession.

In developing the scope of practice statement for registered nursing the Council included the treatment of illness and injury and the planning and implementation of interventions. It was not the intention to exclude palliation but rather the Council felt it was included within the scope statement. However, as a result of the extensive submissions on this point, the Council is prepared to include palliation in the description of what registered nurses do.

Another issue mentioned in several submissions was that diagnosis should be added to the scope statement. The Council has decided not to include diagnosis in the scope statement and will address this issue when it considers reserved acts.

II. RESERVED ACTS

In its Preliminary Report, the Council recommended several reserved acts for registered nurses, some to be performed independently and some to be performed on the order of an authorized health professional:

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

1. 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.

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:

1. 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.
2. Administering by any means a drug listed in Schedule I or II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act.

Most of the submissions at the hearing criticised this portion of the Council’s report. The submissions fell into two general categories. First were those who indicated that many of the reserved acts which the Council had recommended be performed on order were actually performed independently. Second, many respondents objected to the term "order," and felt that it would unduly restrict the practice of nursing. The Council will deal with the second point when it discusses in more detail the issue of order-initiated reserved acts.

On the first point, the Council is satisfied, based on the submissions received at the hearing, that some changes are necessary to its recommendations on reserved acts. In considering these changes, the Council reviewed the controlled acts granted to registered nurses in Ontario, as it is the only jurisdiction in Canada that has formally introduced a regulatory model similar to the one described in the Council’s Terms of Reference.

Diagnosis (reserved act 1)

Reserved act 1 on the Council’s list states as follows:

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

In its Preliminary Report, the Council did not recommend granting diagnosis to registered nurses, and recommended that they only perform diagnosis when it is delegated to them by other health professionals authorized to perform it.

In reaching that conclusion, the Council was mindful of its distinction between assessment and diagnosis that it discussed in the Shared Scope of Practice Model Working Paper (Working Paper). There, the Council described diagnosis as the identification of the cause of signs or symptoms. Assessment was described as a process of observation and evaluation, which may involve observation of symptoms but does not include identifying a disease, disorder or condition as the cause of those symptoms.

The Council felt that the process described by registered nurses is assessment, not diagnosis. At the hearing, the College of Physicians and Surgeons supported this conclusion and stated that "(d)iagnosis is beyond the scope of the average registered nurse."

Several submissions prior to the hearing suggested that most registered nurses do not perform diagnosis. For example, the LPNABC stated:

On review of the information submitted, it appears that diagnosing at a nursing level should be a post-basic competency of the Registered Nurse or that of a Nurse Practitioner. The question may be raised would this be beyond the scope of practice in the majority of cases without post-basic education? The Registered nurse does not have the education of a doctor, lab or x-ray technician.

The B.C. Psychological Association (BCPA) stated that if registered nurses are granted the reserved act of diagnosis, a qualifying statement should be added so that diagnosis of mental illness is a reserved act shared by psychology and psychiatry. The BCPA further stated that registered nurses lack the competency to order or interpret tests regarding possible mental illness or neuropsychological conditions. The College of Psychologists of British Columbia made a similar statement. It contended that registered nurses lack adequate training in diagnosing mental disorders and illnesses and neuropsychological disorders.

With respect to the registered nurses’ request that they be allowed to order tests to undertake differential diagnosis if granted the reserved act of diagnosis, Castlegar and District Hospital stated this reflects a "physician assistant" role which goes beyond current training levels of educational institutions and would lengthen the training course.

The B.C. Medical Association made the following statement:

The statement that "a diagnosis is a diagnosis no matter what profession is performing that function" is unsubstantiated. … It is unreasonable to expect a nurse with either two or four years training to assume the same responsibility as a physician who has studied for nine years.

The BCNU conceded that registered nurses are not competent to perform the whole reserved act of diagnosis as it is worded in the Council’s Reserved Acts List. It stated that while registered nurses do identify conditions as the cause of signs or symptoms in a patient, for the most part registered nurses do not have the entry-level competencies to make such diagnoses.

Several participants at the public hearing submitted that diagnosis is an integral part of registered nursing. For example, the South Fraser Health Region stated:

By excluding diagnosis in the proposed statement, registered nursing practice as it currently exists in the South Fraser Health Region is not represented. Our RNs regularly use diagnosis as part of their daily activities. We believe that diagnosis represents the culmination of assessment, problem solving, professional judgement and decision making.

Similarly, the RNABC stated that it is common for registered nurses to identify diseases, disorders or conditions. However, they acknowledge that diagnosis of diseases and disorders is less common than diagnosis of conditions. They also state that in many cases registered nurses assess clients in order to reach a "presumptive" diagnosis in order to conduct further tests or refer to another health professional.

Several participants referred to the practice of public health nurses, stating that they frequently diagnose communicable diseases. For example, Simon Fraser Health Region states that public health nurses are "frequently contacted by the public to diagnose a communicable disease."

The Council also heard that other specialized or advanced practice nurses, such as those involved in First Call or Outpost Nursing Programs, may diagnose diseases and disorders. However, such diagnosis is generally carried out through detailed guidelines and/or protocols developed by specialist nurses who have advanced training and education. Unlike in Ontario, there is no formal program, recognized through legislation, which permits independent, primary care practice by nursing.

A joint submission to the Council’s Preliminary Report by the B.C. Cancer Agency, Children’s and Women’s Health Centre of British Columbia, Providence Health Care, and Vancouver Hospital and Health Sciences Centre also stated that registered nurses diagnose and that excluding the reserved act of diagnosis from registered nursing practice will have negative consequences for patients. The following groups also submitted that diagnosis should be a reserved act for registered nurses:

• Clinical Nurse Specialist Group at Vancouver Hospital Health Sciences Centre,
• the B.C. Occupational Health Nurses Professional Practice Group – Vancouver Sub-Group,
• the Elk Valley and South Country Nurses Advisory Group, and
• the Vancouver/Richmond Health Board.

The Simon Fraser Health Region also submits that registered nurses diagnose and that they ought to be granted this reserved act. In this regard, the Health Region offered several definitions of the term, including:

Websters definition of diagnosis:

• The act or process of deciding the nature of a diseased condition by examination of the symptoms; a careful examination and analysis of the facts in an attempt to understand or explain something; a decision or opinion based on such examination.
• The ability to "recognize, determine, assess, discern and decide appropriate interventions for clients"
• The statement that registered nurses "state client status in practice setting terminology, using verifiable information"
• "A decision about a problem/need that requires nursing intervention and management"
• It is common nursing practice to examine, assess and analyze symptoms and based on this process to decide a course of action

The Health Region also refers to the term "nursing diagnosis" from the RNABC Standards of Practice which provides:

Nursing Diagnosis. A clinical judgment about individual, family or community responses to actual or potential health problems or life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

The Council has also considered the regulation in Ontario. There, the vast majority of registered nurses cannot communicate a diagnosis. Ontario did however create a special class of registered nurses, the extended class (EC), through which practitioners who meet the legislative requirements can act as independent, primary care practitioners. The entrance requirements include specialized training and education and successful completion of an examination. Members of the EC may communicate a diagnosis but only in a limited fashion. Diagnosis is limited to diseases or disorders that can be identified from

1. the patient’s health history,
2. the findings of a comprehensive health examination, or
3. the results of laboratory or other tests that the member is authorized to perform.

The tests which may be carried out by registered nurses (EC) are limited to those specifically prescribed in the regulations.

Further, registered nurses (EC) who diagnose are required to follow the prescribed standards of practice as set out in the Expectations for Consultation with Physicians by Registered Nurses in the Extended Class (Primary Health Care Nurse Practitioners). The Expectations for Consultation focus on situations in which making and communicating a diagnosis extend beyond primary health care nurse practitioner practice into medical practice. Under the standards, the term consultation means an explicit request by a registered nurse (EC) for a specific physician to become involved in the care of a client for which the registered nurse (EC) has primary responsibility. Consultation is required when the registered nurse (EC) reaches the limits of primary health care nurse practitioner practice, beyond the registered nurse’s (EC) ability for independent care.

The degree of participation by the physician may vary. Consultation may be in the form of an opinion and recommendation; an opinion, recommendation and concurrent intervention; or a transfer of care. The Expectations for Consultation are based on collaboration, assumptions and certain procedural and clinical expectations for consultation. Collaboration means working together with one or more members of the health care team who each make a unique contribution to achieving a common goal. The assumptions include accountability by the registered nurse (EC) and the establishment of a working relationship with the consulted physician, as well as the development of mutually agreeable structures and processes for consultation. The procedural expectations require the registered nurse (EC) to present the reason for and describe the consultation requested. The registered nurse (EC) must also appropriately document the request and outcome of the consultation. The clinical expectations describe in detail the symptoms or signs exhibited by the patient that alert the registered nurse (EC) to consult a physician.

The Council accepts that these statements accurately describe the involvement of registered nurses in "diagnosis." The Health Region’s submission, and many others, are based on the notion that it is inappropriate to distinguish between a "nursing diagnosis" and a "medical diagnosis." Many participants have described the process of nurses arriving at a conclusion and initiating interventions. Many terms were used to define this process, including "presumptive" diagnosis, "interim" diagnosis and "working" diagnosis. Confusion has arisen based on different understandings of the term diagnosis.

In communication with a Practice Adviser of the College of Nurses of Ontario, the difference between medical and nursing diagnosis was clarified. The Practice Adviser described medical diagnosis as done from the perspective of the pathology, physiology and anatomical framework. Nursing diagnosis is the conclusion reached at the end of the assessment of all the factors and is made from the perspective of what the nurse can then do to deal with the condition of the patient. Nursing diagnosis looks at the impact on the patient and at other factors that may stem from the disease. The Adviser stated that nurses do not diagnose the underlying disease but the sequelae.

The Council also found assistance regarding the distinction between medical and nursing diagnoses in the following definitions from Taber’s Medical Dictionary (17^th edition):

Nursing diagnosis: Nurses, esp. those involved in patient care, are in virtually constant need to make decisions and diagnoses based on their clinical experience and judgment. In many instances, that process dictates a course of action for the nurse that is of vital importance to the patient. As the nursing profession evolves and develops, nursing diagnosis will be defined, and indeed specified, in accordance with the specialized training and experience of nurses, particularly for nurse practitioners and clinical nurse specialists.

Medical diagnosis: The entire process of determining the cause of the patient’s illness or discomfort. The method of arriving at the diagnosis will depend upon a number of factors including the type of illness or injury present. Indeed, making the diagnosis of a simple and superficial laceration of the skin of the lower leg will be much less involved than would making the diagnosis of a laceration of the scalp. In the latter, the depth of the wound will be of utmost importance in determining the number of layers of the scalp to be sutured. Also the diagnosis of an obscure infectious disease or of an unexplained fever will involve clinical skills as well as sophisticated laboratory investigations that would not be required to diagnose a simple cold or influenza. Medical diagnosis is to be differentiated from nursing diagnosis, q.v.

Based on its review, the Council concludes that registered nurses do more than assess patients. They also make clinical judgments based on these assessments and take further actions as necessary. This process is described in the RNABC Standards of Practice referred to above. Therefore, the Council recommends the following reserved act for registered nurses which describes the nature of diagnosis in the practice of registered nursing.

Procedures on tissue below the dermis [Reserved Act 2(a)]

In its Preliminary Report, the Council recommended that registered nurses be granted the right to perform any procedures on tissue below the dermis with an order. The Council received several submissions that registered nurses perform many procedures below the dermis independently.

In Ontario, general class registered nurses are entitled to perform many procedures below the dermis, particularly activities associated with wound care and intravenous treatment.

Section 15(4)(1) and (2) of the Ontario Nursing Act Regulations state:

(4) The following are the procedures referred to in subsections (1), (2) and (3):
1. With respect to the care of a wound below the dermis or below a mucous membrane, any of the following procedures:
   1. cleansing,
   2. soaking,
   3. irrigating,
   4. probing,
   5. debriding,
   6. packing,
   7. dressing.

2. Venipuncture to establish peripheral intravenous access and maintain patency, using a solution of normal saline (0.9 per cent), in circumstances in which,
   1. the individual requires medical attention, and
   2. delaying venipuncture is likely to be harmful to the individual.

Many of the submissions provided examples of situations in which nurses perform these services independently. In particular, many submissions referred to registered nurses’ involvement with wound care and intravenous procedures, similar to those granted to registered nurses in Ontario. The Council is satisfied that such services do fall within the core competency of registered nursing.

In its Preliminary Report, the Council recommended that registered nurses be granted this procedure as a reserved act to be performed on order. This is the same situation as in Ontario where general class registered nurses may only administer substances by injection or inhalation on the order of an authorized health professional. Although various nursing groups outlined registered nurses’ involvement with this reserved act, the Council is of the view that such services are performed on the order of another health profession. However, as the Council granted registered nurses the reserved act of venipuncture to establish peripheral intravenous access and maintain patency, using a solution of normal saline (0.9 per cent), this reserved act will have to be modified.

The Council in its Preliminary Report recommended that registered nurses be granted the following parts of this reserved act to perform independently:

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.

Performing the physically invasive or physically manipulative act of 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.

Many submissions at the public hearing disagreed with the Council’s recommendations on this reserved act. The B.C. Nurses’ Union (BCNU), in its response to the Council’s Preliminary Report, stated that the above order-initiated procedures fall within entry level competencies of registered nurses, and therefore, need not be order-initiated reserved acts. Likewise, the B.C. Occupational Health Nurses Professional Practice Group – Vancouver Sub-group stated that occupational health nurses are performing these acts currently without orders.

In Ontario, sections 15(4)(3.), (4.) and (5.) of the Nursing Act Regulations grant the following controlled acts to both general class registered nurses and registered nurses (EC):

3. A procedure that, for the purpose of assisting an individual with health management activities, requires putting an instrument

1. beyond the point in the individual's nasal passages where they normally narrow,
2. beyond the individual's larynx, or
3. beyond the opening of the individual's urethra.

4. A procedure that, for the purpose of assessing an individual or assisting an individual with health management activities, requires putting an instrument or finger

1. beyond the individual's anal verge, or
2. into an artificial opening into the individual's body.

5. A procedure that, for the purpose of assessing an individual or assisting an individual with health management activities, requires putting an instrument, hand or finger beyond the individual's labia majora.

In addition to the foregoing, Ontario registered nurses (EC) are authorized to perform some of these acts specifically for the purpose of assessment or treatment of an individual. Section 17 of the Nursing Act Regulations states:

17. For the purpose of clause 5(1) of the Act, a registered nurse in the extended class may perform any of the following procedures if he or she meets all of the conditions set out in subsection 15(5):

…

3.. a procedure that, for the purpose of assessing or treating an individual or assisting an individual with health management activities, requires putting an instrument

1. beyond the point in the individual’s nasal passages where they normally narrow,
2. beyond the individual’s larynx, or
3. beyond the opening of the individual’s urethra.

At the public hearing the Council heard submissions that registered nurses in B.C. are performing similar activities.

The Council believes that there is an important distinction between performing physically invasive acts for the purposes of assessing an individual or assisting an individual with health management activities and for the purposes of treating an individual. Assessing means observing or evaluating a patient. Assisting with health management activities generally means helping people with self-care and activities of daily living. In contrast, treatment involves the application of a particular procedure for the amelioration or resolution of a disease, disorder or condition. Performing these physically invasive acts for the purposes of treatment presents a greater risk of harm and ought only to be performed by registered nurses on the order of an authorized health professional.

After reviewing these submissions and after examining Ontario’s model, the Council is prepared to change its recommendation with respect to this reserved act.

C. Managing Labour or delivery of a baby (Reserved Act 3)

The Council’s reserved act 3 states, "managing labour or delivery of a baby." The BCNU and RNABC proposed that registered nurses be granted a limited portion of this reserved act: "managing labour and conducting vaginal delivery of a baby within an institutional setting." The joint proposal indicated that a special class of obstetrical nurses, who have additional post-graduate training and expertise in obstetrics, provide these services in many institutional settings.

In its Preliminary Report the Council stated that it did not "doubt that registered nurses are involved in various aspects of managing and conducting delivery." However, the Council felt that such registered nurses "specialize in this practice area," and that these services do not fall within the core competency of most registered nurses.

Several submissions received prior to and at the hearing reiterated the BCNU/RNABC proposal, and indicated that registered nurses frequently perform services in this area.

The RNABC submitted:

As indicated in the RNABC-BCNU joint submission to the Health Professions Council, managing labour currently falls within the scope of nursing practice (BCNU & RNABC, p. 16). Other than prescribing medications, nurses manage the normal progress of labour and identify any deviations from normal. Theses are entry-level competencies for registered nurses and are in the blueprint for the Canadian Registered Nurse Examination (1999). Most nurses who work in the perinatal area have more advanced competencies, which they have attained through specialty certification programs such as BCIT’s certification program for perinatal nursing. RNABC believes that independent authority for the reserved act of managing labour must be granted to registered nurses.

…

Conducting a normal vaginal delivery of a baby within an institutional setting is common to perinatal registered nursing practice. RNABC believes it is not appropriate to use the emergency exemption for reserved acts for managing deliveries when this is a common occurrence and nurses in many settings are expected to deliver babies in the absence of the primary provider.

Many submissions at the hearing gave examples of registered nurses’ involvement in this reserved act. Some referred to registered nurse involvement in monitoring labour; virtually all indicated that registered nurses are frequently called upon to deliver babies when physicians are unavailable. Generally, all participants conceded that this is an area of specialized practice for registered nurses. For example, the Simon Fraser Health Region stated:

Managing labour and delivery in institutional settings is a specialized nursing practice. Nurses employed in these areas within SFHR have the specialized knowledge, education and experience to practice in labour and delivery and in fact are required to possess such advance education, certification and experience prior to hiring. In addition, their competency is maintained and assessed annually through ongoing formal orientation, education and clinical practice support.

The discussion of this reserved act raised a more general criticism of the Council’s preliminary recommendations, one which was advanced strongly by the RNABC. It stated that the Council’s preliminary reserved act only granted reserved acts when it was satisfied that services fell within the core competency of registered nurses and thus failed to recognize advanced and specialized nursing practice.

The Council does not doubt that registered nurses with specialty training do perform the services proposed by the BCNU/RNABC, but we were not presented with detailed information about the programs in place to allow for advanced training and education of such practitioners. Moreover, the information received at the hearing confirmed that there is no universally accepted certification system in place, and a wide array of training and educational programs, which vary amongst institutions, are used to establish advanced practice capability. Such diverse arrangements are not in the public interest, and universal certification programs, regulated through the College, ought to be established for specialty and advanced practice. Indeed, the Council notes that both the RNABC and BCNU conceded towards the end of the hearing that additional regulatory mechanisms ought to created. Both groups made detailed written submissions on this issue after the hearing.

The Council is prepared to recommend the granting of this reserved act to registered nurses to perform independently but only if additional regulatory mechanisms are established. This issue will be discussed further in the advanced/specialized practice section of this report.

In its Preliminary Report the Council decided that applying hazardous forms of energy is not within the core competency of registered nurses to perform independently. The Council did, however, recommend that registered nurses be entitled to perform this reserved act as a delegated function.

In Ontario, general class registered nurses are not authorized to perform this controlled act. However, registered nurses (EC) in Ontario are authorized to order x-rays and diagnostic ultrasounds. With regard to x-rays, registered nurses (EC) are authorized to order x-rays of the chest, the ribs, the arm, the wrist, the hand, the leg, the ankle or the foot of a human being, and mammography. Registered nurses (EC) are not authorized to operate the x-ray machine. With respect to ultrasounds, registered nurses (EC) are authorized to order the application of soundwaves for a diagnostic ultrasound of the abdomen, the pelvis (including obstetrical ultrasound) and the breast. It does not include performing or interpreting the ultrasound. Any other x-ray or ultrasound must be ordered by a physician either by means of a medical directive or a client-specific order.

Many participants submitted that registered nurses should be granted this reserved act. The Health Employers Association of British Columbia commented:

Nurses in acute care settings and rural clinics are required to apply potentially hazardous forms of energy in several ways, including cardiac defibrillation, external cardiac pacemakers, TENS (transcutaneous electric neuromuscular stimulator) as a pain control method, electrocardiography, ordering of x-rays and neonatal monitoring through ultrasound.

The RNABC believes that registered nurses perform this reserved act so frequently that it does not require additional regulatory mechanisms.

The Simon Fraser Health Region stated:

RNs initiate (order) X-rays routinely to confirm tube placements. This ensures safe and prompt instillation of enteral and parenteral substances. RNs apply electrical energy independently during cardiac arrest management (defibrillation) and adjust external pacemaker setting to ensure capture. In maternal child areas RNs routinely apply bilirubin lights to neonates. All of these practices are governed by agency guidelines, protocols and standards which have been developed by interdisciplinary teams at the regional level. RNs receive formal training and yearly testing in these specialized skills. Standards and protocols are annually reviewed to ensure best practice. [Emphasis added.]

The Council accepts that portions of this reserved act are often performed by registered nurses in many different settings. As confirmed in the Simon Fraser Health Region submission, the activities described in the submissions are generally performed under protocols, guidelines or patient-specific orders, and not independently. The Council now recommends that this reserved act should be an order-initiated act and not one performed as a delegated function.

In its Preliminary Report, the Council determined that the reserved act of administering a drug independently is not within the core competency of most registered nurses and therefore recommended it as an order-initiated reserved act. The Council did not grant registered nurses the reserved act of compounding a drug. This is similar to the situation in Ontario where general class registered nurses must receive an order to administer drugs and registered nurses were not granted compounding.

In Ontario, registered nurses (EC) have a broader scope to perform this reserved act. They are authorized to prescribe a range of drugs as per section 5.1(1)3 and 5.1(1)4 of the Nursing Act which state:

3.     Prescribing a drug designated in the regulations.

4.     Administering, by injection or inhalation, a drug that the member may prescribe under paragraph 3.

The Ontario Nursing Act Regulations list the specific drugs registered nurses (EC) may prescribe:

19.(1) For the purposes of paragraph 3 of subsection 5.1(1) of the Act, the following drugs are designated:

1. An immunizing agent set out in Schedule 2.
2. A drug set out in Schedule 3.
3. Any drug that may be lawfully purchased or acquired without a prescription.

(2) If circumstances are set out opposite a drug set out in Schedule 3, a registered nurse in the extended class shall only prescribe the drug under paragraph 2 of subsection (1) in those circumstances.

The Ontario Standards of Practice for Registered Nurses in the Extended Class describes this reserved act in greater detail. Basically, Schedule 2 lists immunizing agents and Schedule 3 lists drugs that an registered nurse (EC) may prescribe. Section 19 (2) restricts the use of some of these substances by specifying the route and/or purpose for which they may be used. Thus, registered nurses (EC) cannot independently prescribe or administer substances not included on the lists and, for drugs for which the proposed purpose or route is included on the list, must comply with the stated requirements. Over the counter drugs are not included on the list as they do not require a prescription.

1. Compounding

The Council received submissions indicating that registered nurses in B.C. frequently compound substances as, for example, when drugs or supplements are added to IV solutions. The Council accepts this submission and believes that the act of compounding should be granted as a reserved act for registered nurses to be performed on order.

Thus, registered nurses will be entitled to compound a drug on the order of an authorized health professional.

2. Administration of Schedule II Substances

The Council also heard that registered nurses routinely recommend and administer substances on Schedule II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act. Schedule II includes substances which are available without prescription but are kept in restricted areas of a pharmacy. Several submissions questioned why registered nurses should be prevented from accessing and using these substances when they are widely available to the public. The Council accepts these submissions.

Finally, the Council notes that BCNU, in its submission dated 5 June 2000, requests that reserved act 5(b) (designing, compounding or dispensing therapeutic diets) be granted to registered nurses "either by inference or necessary implication." BCNU states that neither RNABC nor BCNU requested this reserved act in their joint submission of March 1999 since the reserved act was first articulated by the Council only in August 1999. RNABC raised this issue with the Council in its response to the Council’s application report on dietetics. BCNU contends that registered nurses design therapeutic diets for enteral administration and compound diets by mixing ingredients. It concedes, however, that registered nurses do not design or dispense diets for parenteral administration, and that registered nurses would require some minimum amount of post-basic training to perform this reserved act competently.

The Council is satisfied that this reserved act should be granted to registered nurses on order.

In its Preliminary Report the Council did not address this reserved act as it was not raised by the RNABC. In its presentation at the public hearing the RNABC stated:

This reserved act was not requested in the original RNABC-BCNU joint proposal. Registered nurses do not initiate this reserved act independently. However, they frequently carry out this act under the order of a physician and are able to recognize and treat anaphylaxis when necessary. RNABC requests that the Health Professions Council clarify that registered nurses are able to carry out these activities when they have a physician’s order and not through delegation.

lll. RESERVED TITLES

The Council’s Preliminary Report recommended the following reserved titles for registered nurses:

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

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

Although the title "Christian Science Nurse" appears in the current Nurses (Registered) Act, RSBC 1996, c. 335, the Council received no comment or submission on this title, nor did any of the nursing groups reviewed by the Council request this title. Therefore, the Council did not recommend that it be reserved.

IV. THE MEANING OF ORDER

In the Preliminary Report, the Council recommended that registered nurses be granted the right to perform several reserved acts on the order of another health professional who is authorized to perform the reserved act independently. There was widespread criticism of this term which indicated variously that such a requirement would seriously impair the ability of registered nurses to assist patients in a timely and effective manner. Much of this criticism is misplaced as it is based on a misunderstanding about the use of the term "order." The Council did not intend the term to be interpreted as requiring a patient-specific instruction in every case. Rather, the term was meant to encompass the many means by which registered nurses currently perform many services.

The Council was presented with several different definitions of the term "order." Indeed, it appeared that each speaker had its own interpretation of the term, none of which properly conveyed the Council’s intention as expressed in the Preliminary Report. In commenting on the issue of "orders," the BCNU made a valuable submission regarding terminology:

[T]he BCNU would caution the HPC not to rely on terms or definitions that different parties use in different context.

…

Because there is no agreement as to what these terms [protocols, guidelines] mean or a consensus that the HPC could rely on, the BCNU would suggest that it would be very useful if the Council created Its own definitions of the terms it uses. In that way, everyone reading the Council’s final report will be working from the Council’s understanding of these terms, rather than applying their own, perhaps mistaken, interpretations.

In this respect, it is not critical that the HPC’s definitions correspond with any particular definition used in the literature, the common law or current practice. The BCNU would suggest that what is more important is that these terms be defined by the Council so that their subsequence use by the Council can be understood by all without the need for further research or debate. In doing so, it is also important that the Council make it clear what the differences are between its defined terms.

The Council agrees with this submission and will clarify what was meant by the use of the term "order." Virtually all of the submissions dealing with this issue referred to such terms as "clinical practice guidelines," "clinical practice standards," "agency protocols" and "pre-printed orders." For example, the Simon Fraser Health Region, in speaking about various reserved acts, stated, "RNs develop and are guided by clinical practice guidelines and agency protocols for the safe enactment of these competencies." The submission also indicated that these processes are generally created through a collaborative process involving administrators and health care professionals.

Simon Fraser Health Region included several examples of such guidelines and protocols with its submission. As a general comment, it stated that regulatory structures must be "flexible" and create the ability to "adapt to the increasing chaos of change." The Council supports the need for flexibility, and indeed its intention with regard to order-initiated reserved acts was intended to ensure first, public safety and second, that health professionals and administrators would develop the processes themselves to meet the needs of the public. In other words, the Council’s impression was that the present system of guidelines and protocols works well and should be facilitated by our recommendations.

For example, the Council heard from several participants at the hearing about public health nursing. The deputy provincial health officer stated:

As you have heard from my co-presenters, 50 per cent of B.C.’s routine immunizations are delivered by trained public health nurses operating according to defined provincial program policies and standards.

Similarly, prior to the hearing, the Public Health Nursing Leaders’ Council stated:

Historically, public health nursing practice has been guided by various acts and regulations and by delegation of function by the medical officer of health.

…

For instance, the medical health officer is charged with responsibility for the health safety of children in the school setting. This duty is discharged by delegation of function to various health professionals, including public health nurses who provide well-defined immunization programs and work collaboratively with school district staff in the promotion of health and prevention of disease in the school population.

…

The current process of delegation as outlined in the Health Act is the most prudent for the delivery of population based services.

The process followed by public health nurses is set out in the Health Act, RSBC 1996, c. 179, and its regulations. The B.C. Centre for Disease Control is the primary co-ordinating body for prevention and control of communicable diseases in the province. Its authority to act on behalf of the provincial health officer is set out in the Health Act.

At the hearing, the College of Physicians and Surgeons of British Columbia stated that primary immunization programs:

[are] delegated by the provincial health officers to public health nurses with carefully worked out protocols for preliminary assessment, recognition of contraindications, administration and the giving of advice regarding complications and their management.

At the local level, immunization programs are carried out by local health authorities. Within each health authority, the medical health officer is responsible for prevention and control of communicable diseases in the community. Public health nurses collaborate with the medical health officers to provide immunizations and, where applicable, distribute vaccines to physicians and health care facilities in the community. Public health nurses deliver immunization through provincial policy and guidelines. The B.C. Centre for Disease Control’s manual, Communicable Disease Control Immunization Program is one such guideline. Public health nurses must undergo an orientation process where they are supervised by more senior public health nurses before actual immunizations are performed.

The Ontario Standards of Practice for Nurses in the Extended Class contains a useful discussion of the term "medical directive" which serves to clarify further the Council’s intention:

What is a "Medical Directive"?

First, it is important to understand what the terms "medical directive" and "medical protocol" mean, and how they relate to the terms "order" and "standing order".

• A medical "order" is a prescription for treatment or an intervention. It can apply to an individual client by means of a client-specific order, or to more than one individual by means of medical directive. As such, a medical order exists in one of two forms:
  • A "direct order" is client specific. It is a prescription of a procedure, treatment or intervention of a particular client, is written by an individual physician for a specific procedure/treatment/intervention to be administered at a specific time(s).

  • A "medical directive" or "medical protocol" is not client specific. It is a prescription for a procedure, treatment or intervention that may be performed for a range of clients who meet certain conditions. The medical directive identifies a specific treatment or range of treatments, the specific conditions that must be met and any specific circumstances that must exist before the directive can be implemented.

The Ontario Standards of Practice for Nurses in the Extended Class also states that the term "standing order" is not supported by either the College of Nurses of Ontario or the College of Physicians and Surgeons of Ontario:

In the past, a "standing order" was implemented for every client, regardless of the circumstances, with no judgment expected by the person implementing the order regarding its appropriateness. It is now recognized that knowledge, skill and judgment are critical, and that no order for treatment, regardless of how routine it may seem, should be automatically implemented.

Thus, in Ontario the term order refers to both patient-specific and general orders, but not standing orders. Similarly, the Council intended that the term order encompass both. The Ontario Standards of Practice provides further details about orders.

When is a Medical Order Required?

The health care team needs to determine whether a procedure can safely be ordered by means of a medical directive, or whether direct assessment of the client by the physician is required before the procedure is implemented. Procedures that require direct assessment of the client by the physician require a client-specific order.

What Information Does a Medical Directive Need to Include?

There are a number of specific components required in a medical directive. These are:

• A description of the procedure(s) being ordered;
• Specific client conditions which must be met before the procedure(s) can be implemented;
• any circumstances which must exist before the procedure(s) can be implemented; and
• any contraindications for implementing the procedure(s).

The degree to which client conditions and situational circumstance are specified will depend on the client population, the nature of the orders involved and the expertise of the health professionals implementing the directive. The following are also required:

• the name and signature of the physician authorizing the medical directive; and
• the date and signature of the administrative authority approving the medical directive (for example, the Intensive Care Unit Advisory Committee).

Who Should be Involved in the Development of a Medical Directive?

A medical directive is an order for one or a series of procedures. Although it is by definition a medical document, the collaborative involvement of health care professional affected directly or indirectly by the medical directive is strongly encouraged.

The Council’s intention was that an order could apply generally or to a specific patient. The professions involved in the process should develop orders of a general nature which would authorize nurses to proceed to perform the reserved acts assigned to them for certain classification of patients in situations which meet the criteria and parameters set forth in the general orders. Specific orders would continue to be used as they are now in those situations where, for example, medical practitioners order specific reserved acts to be preformed on specific patients. A number of submissions acknowledge that this does not represent a marked departure from the current practice and that such protocols or orders are in fact generally in place.

The Council expects the professions themselves, together with others involved in the process such as hospital administrators, to work together to determine the best way to implement the initiation of reserved acts where the interest of the patients require them to be done by registered nurses who have the competence to perform them.

V. ADVANCED PRACTICE/PRIMARY CARE NURSING

Several submissions suggested that the Council’s Preliminary Report addressed only entry level competencies and did not recognize that many registered nurses attain advanced competencies through specialized training and education as they progress through their career. Other submissions outlined the various specialty areas for registered nurses. For example, the Simon Fraser Health Region described several areas of specialized practice including renal services, emergency care, public health, mental health and maternal-child. Still other submissions criticized the Council for failing to consider primary care nursing performed by, for example, public health nurses, outpost nursing and nurses acting within the First Call Program.

The First Call Program was developed as a joint solution to a physician shortage by registered nurses, physicians and the Ashcroft Hospital together with the BCNU and RNABC. The First Call model is based on a triage system, where a registered nurse assesses a patient admitted to emergency and assigns a level of care: non-urgent, urgent or emergent. Nurses wishing to practise within the First Call Program are required to complete an education program at the University College of the Cariboo and demonstrate competence in practice.

The common element in all of these practice areas is that these registered nurses have additional training and education to perform services beyond entry level competencies.

The Council strongly supports the individuals and agencies which have taken the initiative to create these advanced and specialized programs. Clearly, the programs are in the public interest and represent a valuable addition to the health care system. However, the Council is concerned that there is little consistency in the programs in use at present. Currently, a wide array of mechanisms are used to ensure competency, virtually all of which are created and followed by employers without RNABC oversight. These mechanisms include agency based training and education, certification through various national nursing bodies and education through the community college system. While this diverse system for achieving advanced competency has a necessary element of flexibility, the Council believes strongly that the RNABC needs to take a more active role in regulating advanced and specialized practice. Without a centralized, universal system for evaluating and monitoring competency for such practitioners, the Council is reluctant to recommend the granting of specific reserved acts to advanced or specialized registered nurses.

Some participants at the hearing supported the Council’s views on this issue. For example, a joint presentation by the B.C. Cancer Agency, Children’s & Women’s Health Centre of B.C., Providence Health Care, Vancouver Hospital and Health Sciences Centre stated:

It is understood that nurses who have advanced educational preparation and extensive experience in a particular clinical practice area are more competent to initiate reserved acts that may carry substantial risk than are novice practitioners. It is legitimate to question how the profession will control the initiation of reserved acts to those who have the necessary competence. However, rather than limit the independent performance of reserved acts for all nurses to those that can be safely performed by novice practitioners we would urge the HPC to challenge the regulatory body to develop mechanisms to regulate nurses performing reserved acts, including: managing labour (Reserved Act 3), ordering hazardous forms of energy (Reserved Act 4) and prescribing, compounding, dispensing (Reserved Act 5). The model should require that nurses proposing to perform the above-named reserved acts be allowed to do so only after providing evidence of competence to the regulatory body. [Emphasis added.]

Both the BCNU and the RNABC also recognize the need for additional regulatory mechanisms in this area. The RNABC acknowledges that while many registered nurses acquire additional training and education, there is currently no consistent, formal system in place to recognize advanced competency of registered nurses. The RNABC stated that it is in the process of developing just such a system which is described in its submission:

The Regulatory Framework

RNABC has identified that for some reserved acts, such as prescribing, additional regulatory mechanisms will be required. This will be addressed using a combination of two approaches – through regulation of the process and through regulation of the individual.

Regulation of the Process

Regulation of the process would be modeled on the current specialized nursing skills system. Specialized nursing skills are generally not part of a basic nursing education program, but are acquired through a post-basic nursing education or inservice program. The decision to designate an activity as a specialized nursing skill rests with the agency. Where reserved acts require additional regulatory mechanisms, organizations wishing to authorize registered nurses to carry out activities within these reserved acts will be required to follow the Rules under the Nurses (Registered) Act established by RNABC. Regulation of the process will be used only when the reserved act is carried out in limited circumstances. Examples of activities that could be regulated this way include RN First Call protocols that include the prescribing of medication, administration of listed drugs (based on protocol rather than physician orders) carried out by registered nurses in a variety of critical care areas, treatment of sexually transmitted disease, and provision of birth control pills. Standing orders from physicians will be neither needed nor acceptable. Regulation of the process requires that registered nurses are authorized by their employer to carry out these activities.

RNABC will develop rules related to five areas that will need to be adhered to by organizations wishing to authorize registered nurses to carry out reserved acts requiring additional regulatory authority. The five areas are :

• determination of client best interest;
• development of the protocol;
• template for the protocol;
• certification; and
• qualifications of instructor.

RNABC currently does not have authority at the organizational level. The best way to ensure that rules are adhered to at the organizational level needs to be established in discussion with stakeholders.

Regulation of the Individual

These individuals will practice in a broad variety of environments including acute care, residential care, mental health and community practice (including primary health care settings). The common characteristics of registered nurses in these roles include a specialized knowledge base and a wide variety of activities that require a high degree of independent judgment in initiating and carrying out reserved acts not currently within the scope of practice of all registered nurses (e.g., prescriptive authority).

RNABC will outline the broad competencies needed by registered nurses in these roles. A system will be developed to verify the competencies of these registered nurses prior to authorizing them to carry out activities that require additional regulatory mechanisms. The competencies should be used in the development of educational programs to prepare these registered nurses. RNABC is participating in a national process with the Canadian Nurses Association and all provincial and territorial regulatory bodies for registered nursing to consider the development of common competencies and a national system to verify competencies. The need for an additional title for these registered nurses is also being considered.

RNABC believes that the scope of practice of registered nurses, regulated as individuals by RNABC, should not be limited by the use of lists of drugs and diseases. The scope of nursing is too broad and the contexts in which nurses practice are too varied to effectively define a list of diseases and medications that registered nurses are qualified to treat and prescribe. RNABC will develop a profile of practice that will outline the competencies that registered nurses must achieve, the common contexts of practice and any limitations on the practice of these individuals.

Thus, the RNABC is suggesting that a regulatory system combining both specific tasks (regulation of the process) and classes of nurses (regulation of the person) be developed to address the issue of advanced and specialty practice.

The Council supports this initiative. It is important that the RNABC, as the regulatory body for registered nurses, maintain a strong supervisory role in this process. However, the Council has one concern about the RNABC proposal. On regulating the process, the regulatory mechanism must not simply direct that advanced and specialized competency programs be established by agencies and employers in accordance with RNABC guidelines. The RNABC should be responsible for approving such programs.

As discussed above, primary care nursing is one of several advanced or specialized nursing practices. The Council recognizes the urgent need for programs such as First Call. We support any measures undertaken by health care providers to augment the province’s health care system in the public interest. The Council has been provided with overwhelming evidence that advanced practice registered nurses performing as primary care practitioners in various federal or provincial programs are performing several reserved acts safely and independently. This expansion of the traditional role of registered nurses is in the public interest.

However, the Council is concerned that proper regulatory mechanisms are not in place to govern these activities. Unlike Ontario, B.C. has not established a legislatively defined class of advanced nurse practitioner. The Council believes, and the BCNU and RNABC acknowledge, that a formal regulatory system is necessary and could become part of the RNABC’s proposal for regulation of the individual. Any advanced practice programs must be supported by detailed legislative and regulatory mechanisms, such as those proposed by the RNABC. The new system likely would include provisions for such registered nurses to perform reserved acts additional to those granted to the general class of registered nurses. In order to ensure accountability of the profession, all regulatory mechanisms in this area should be set out in regulations to be approved by Cabinet.

The Council believes that the new regulatory model provides the structure necessary to promote both primary care nursing and advanced practitioner nursing.