Health Professions Council
Licensed Practical Nurses
Scope of Practice Preliminary Report


Irvine E. Epstein, Q.C., Chair
Arminée Kazanjian, Member
David MacAulay, Member

April 2000

This Preliminary Report should be read
in conjuction with the Post-Hearing Update for the profession.

FOREWORD

This report is the result of the Health Professions Council's review of the scope of practice of nursing by licensed practical nurses 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 LPNs 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 licensed practical nurses.

CONTENTS

EXECUTIVE SUMMARY

I. INTRODUCTION

  1. THE NATURE OF THE REVIEW

  2. THE PROCESS FOR THE REVIEW

  3. THE REGULATION OF LICENSED PRACTICAL NURSING

II. THE POLICY BACKGROUND

III. DISCUSSION OF ISSUES

  1. SCOPE OF PRACTICE

    1. Current Scope of Practice of Nursing by Licensed Practical Nurses
    2. Proposed Scope of Practice
    3. Regulation of Licensed Practical Nurses in Other Provinces
    4. Responses to Consultation
    5. Responses to Proposal to
      Eliminate Supervision Requirement

    6. The Council's Conclusions

  2. RESERVED ACTS

    1. Proposed Reserved Acts
    2. Responses to Revised Reserved Acts Proposal
      1. Making a diagnosis
      2. Physically invasive or manipulative procedures
    3. The Council's Recommendations

  3. SUPERVISED ACTS

  4. RESERVED TITLES

  5. OTHER ISSUES

    Abolition of Separate Nursing Professions

IV. RECOMMENDATIONS

APPENDIX A: TERMS OF REFERENCE

APPENDIX B: LIST OF RESERVED ACTS

APPENDIX C: GLOSSARY AND ABBREVIATIONS OF NAMES

EXECUTIVE SUMMARY

The Health Professions Council has conducted a review of the scope of practice of nursing by licensed practical nurses (LPNs).

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 licensed practical nurses:

    The practice of nursing by licensed practical nurses is the provision of health care for the promotion, maintenance and restoration of health; and the treatment and prevention of illness and injury, including assessment of health status and implementation of interventions.

  2. The Council recommends that the following reserved acts be granted to licensed practical 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;

      2. administering a substance by injection, inhalation, irrigation, or instillation;

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

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

        2. beyond the pharynx,

        3. beyond the opening of the urethra,

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

        5. beyond the anal verge, or

        6. 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 Schedule Act.

  3. 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.

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

    • Licensed Practical Nurse;
    • L.P.N.;
    • Practical Nurse; and
    • P.N.
  5. The Council recommends that the title "nurse" be reserved for licensed practical nurses, registered nurses, registered psychiatric nurses, and Christian Science nurses.




I.     INTRODUCTION

A.     THE NATURE OF THE REVIEW

This is the preliminary report of the review of the scope of practice of nursing by LPNs 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 Referencedirect the Council to review the scopes of practice of the recognized health professions, of which licensed practical nursing 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 Licensed Practical Nurses Association of BC (LPNABC) and the College of Licensed Practical Nurses of BC (CLPNBC, at that time known as the "BC Council of Licensed Practical Nurses") on April 19, 1995.

The LPNABC submitted its brief on June 29, 1995 and the CLPNBC submitted one on July 12, 1995. The Hospital Employees’ Union (HEU), which represents most LPNs, also made a submission regarding the scope of practice for licensed practical nurses on June 29, 1995. The submissions were 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.

In 1998, the Council issued the Shared Scope of Practice Model Working Paper (Working Paper) which discusses the Council's list of reserved acts. Health professions were invited to make a submission regarding the Working Paper. The CLPNBC made two submissions in response to the Working Paper, one in April 1998 and the other in July 1999. The HEU also made a submission on April 14, 1998.

Finally, in July 1999, the CLPNBC responded to a joint submission by the Registered Nurses Association of BC (RNABC) and the BC Nurses’ Union (BCNU) on the scope of practice of nursing by registered nurses (RNs). The LPNABC responded to the joint submission in August 1999. These submission contain material pertinent to this review.

The Council has carefully considered all of this information in drafting this preliminary 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 is currently scheduled for 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 LPNABC and the CLPNBC and to the responses received during the consultation process. The Council has abbreviated its references to many of the respondents and for ease of reference, the Council has included as an Appendix C a glossary and abbreviations of names used in this report.

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




C.    THE REGULATION OF LICENSED PRACTICAL 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 nurse registration. In BC it was known as the Registered Nurses Act, SBC 1918, c.65.

In 1951, the first provincial legislation on licensed practical nurses was enacted with the Practical Nurses Act, SBC 1951, c.58, when the Council of Practical Nurses was established. In 1985, the Council of Practical Nurses was renamed the Council of Licensed Practical Nurses. Also in 1985, the title of the Act was changed to the Nurses (Licensed Practical) Act, to emphasize the licensing requirements.

The 1993 Health Professions Statutes Amendment Act set out the duties and objects of the Council of Licensed Practical Nurses, enhanced the Council's powers to investigate the practice of members of the profession, and permitted the Council to suspend or impose limits, in appropriate circumstances, on the practice of a member pending the completion of a hearing concerning the member's practice.

In 1994, the Licensed Practical Nurses Association of BC applied to the Ministry of Health for designation of licensed practical nursing under the HPA. In May, 1995, the Nurses (Licensed Practical) Act was repealed, and LPNs are now governed by the HPA and the Nurses (Licensed Practical) Act Regulation. The name of the regulatory body was changed to the College of Licensed Practical Nurses.




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 in mind, the Council proposes to consider the practice of nursing by LPNs 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 statement describes what the profession does, the methods it uses, and the purpose for which it does it. Unlike the present legislative scheme, 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 Licensed Practical Nurses

The scope of practice for nursing by LPNs is set out in the Nurses (Licensed Practical Act) Regulation under the HPA:

Scope of practice

4.

A registrant may provide such nursing services related to the care of patients as are consistent with his or her training and ability.

Limitations on practice

5.(1)

Except in an emergency, all nursing services provided by a registrant must be carried out under the direction of a medical practitioner who is attending the patient or under the supervision of a registered nurse who is providing services to the patient.

(2) Subject to section 4, a registrant may provide a nursing service for a patient in a private home provided that the attending medical practitioner gives directions.

(3) A registrant may not give nursing service to patients except in accordance with this section and section 4.




2. Proposed Scope of Practice

The CLPNBC and the LPNABC made separate proposals regarding scope of practice statements.

In its initial submission to the Council, the CLPNBC proposed the following scope of practice:

Fully Licensed practical nurses provide professional nursing care and promote health and healing, independently or in partnership with other health care professionals/providers to individuals, families, groups and communities, in a variety of care settings (acute care, home care, community, and long term care/extended care). Where the client has a well-defined health challenge with predictable outcomes the fully licensed practical nurse may function independently within their level of competence. As the acuity or complexity of care increases, and/or outcomes are not predictable and an advanced level of knowledge is required, the fully licensed practical nurse must work in partnership with other health care professionals as an interdependent member of the team to meet the care needs of the client(s). The practice of the fully licensed practical nurse is based on knowledge derived from physical, biological, behavioral and nursing arts and sciences, common to all nurses and in accordance with the standards of practice and guidelines established by the College of Licensed Practical Nurses of B.C.

The LPNABC proposed the following scope of practice:

[T]he practice of nursing is the promotion and education 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.

Both the LPNABC and the CLPNBC also proposed that there should be no provision in the scope of practice statement requiring supervision and direction of the fully licensed practical nurse by a registered nurse or physician.

The CLPNBC emphasizes that as professional practitioners, whose practice is monitored and regulated, its members should not be under the supervision or direction of another professional when they are providing care within their own level of competence.

In addition, the CLPNBC also proposed to include in its scope statement a provision for conditionally or partially licensed practical nurses (individuals grandfathered into licensure) as follows:

Conditionally and partially licensed are individuals grandfathered into licensure and who may, within a facility, assist the fully licensed practical nurse, the registered nurse or the registered psychiatric nurse in the delivery of nursing care under the *direct supervision of those individuals. They function in accordance with the Standards of Practice and guidelines provided by the College of Licensed Practical Nurses.

*The term "direct supervision" should be interpreted to indicate that another registered/licensed caregiver should be immediately available in the vicinity if required. It does not indicate that they must be in the specific room.

However, after reviewing the RNABC's response to the proposal and in particular the criticism of the dual classes of licensure, the CLPNBC amended its proposal to remove the reference to conditionally or partially licensed individuals, indicating that the conditional and partial registrants met the requirements for registration when they joined the profession and thus should not be treated differently in the legislation. The CLPNBC also removed "confusing" language such as "stable", "unstable" and "predictable" because it felt the terms were not universally understood and placed artificial restrictions on LPN practice.

In its 1998 submission to the Council in response to the Working Paper, the CLPNBC submitted the following revised scope of practice statement:

  • Licensed Practical Nurses provide professional nursing care and services to promote health and healing, independently and in partnership with other health professionals or providers to individuals, families and groups, in a variety of settings where nursing care and services are required or requested including acute care, continuing care, community and home care.

  • The practice of Licensed Practical Nurses is based on knowledge derived from the physical, biological, behavioral and nursing arts and sciences common to all nurses and in accordance with the Standards of Practice and guidelines established by the College of Licensed Practical Nurses of B.C.

The proposal was supported by the Health Employees’ Union (HEU) which also submitted that the supervision requirement be removed.

The HEU also provided background for its support of the CLPNBC’s proposal:

Since the early 1980s, HEU has raised two pressing LPN issues: the underutlization of LPNs and their displacement by registered nurses. As well, in recent years it has become increasingly apparent that the shift to community-based health care has implications for the nature of the work done by LPNs, and thus, scope of practice legislation must also address this issue. HEU expects that legislating scope of practice for LPNs will ensure an integral role for LPNs in the health care team and within the context of our evolving health care system.

Elsewhere in its submission, the HEU refers to the following recommendations of the Seaton Commission:

[that] the Ministry of Health require the use of licensed practical nurses and registered psychiatric nurses in hospitals, long term care facilitates, and elsewhere, where their employment is consistent with efficiency and quality care

and that

there be a continuum of education from nurses’ aide to LPN to Baccalaureate RN, and that nurses licensed at each level of the continuum be employed at the highest level possible given their skills. Professional associations should not have the power to interfere with this policy.

The HEU also states:

HEU believes that LPNs should be free to do the work they are trained for without the supervision of RNs or physicians. This is especially important as health care moves out of large hospitals and into the home and smaller facilities. Where their work involves treatment of patients, LPNs are obliged like other health providers to record what they have done.

The CLPNBC also proposed that all reserved acts granted to the profession should be contained in the scope statement. However, as this Council has noted in previous reports, the scope of practice statement is intended to be a general statement, and does not include listings of specific reserved acts. Reserved acts will be dealt with in another section of this report.




3. Regulation of Licensed Practical Nurses in Other Provinces

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

In Ontario, nurses are governed by both the Regulated Health Professions Act, 1991 and the Nursing Act, 1991. 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.

The definition applies to both registered nurses and registered nursing assistants.

In New Brunswick, there are two regulated health professionals providing nursing services: the registered nurses and the registered nursing assistants. "Nursing assistant" is defined in the Registered Nursing Assistants Act, 1977, as follows:

"nursing assistant" means a graduate of an approved school of nursing assistants who, being neither a registered nurse nor a person in training to be a registered nurse, undertakes the care of patients under the direction of a registered nurse or a duly qualified medical practitioner, for custodial, convalescent, sub-acutely ill and chronically ill patients and who assists registered nurses in the care of acutely ill patients, rendering the services for which he or she has been trained.

In Alberta, licensed practical nurses are defined in the Licensed Practical Nurses Regulation AR 97/103 as follows:

(1) A Licensed Practical Nurse, on being delegated under subsection (4) and within the guidelines approved by the Board, may provide the following services:

  1. collect health data from appropriate sources using established assessment format to contribute to the identification of a client's health care needs;

  2. organize the data in order to plan and implement appropriate care;

  3. participate in the plan of care by carrying out nursing treatments and interventions;

  4. prepare clients for tests, surgery and other procedures;

  5. evaluate the effect of interventions;

  6. confer with appropriate regulated health professionals;

  7. document and communicate data for clients to provide continuity of care;

  8. implement an individualized teaching plan in order to promote, maintain and restore health.

(2) A Licensed Practical Nurse, on being delegated under subsection (4) and within guidelines approved by the Board, may provide the following services:

  1. prepare and administer percutaneous medications;

  2. prepare and administer oral and subcutaneous medications if the Licensed Practical Nurse has

    1. graduated after 1995 from a program of studies referred to in section 2(1)(a), or
    2. completed advanced training approved by the Board;
  3. assess and maintain intravenous infusions if the Licensed Practical Nurse has

    1. graduated after 1994 from a program of studies referred to in section 2(1)(a), or
    2. completed advanced training approved by the Board.

(3) A Licensed Practical Nurse who has received advanced training approved by the Board may, on being delegated under subsection (4) and within guidelines approved by the Board, provide services in specialized areas, including but not limited to the following:

  1. operating room;

  2. advanced orthopaedics;

  3. dialysis.

(4) A regulated health professional who

  1. has knowledge of the educational preparation of Licensed Practical Nurses and the nursing services they are qualified to provide, and

  2. has the authority for the appropriate delegation of client services may delegate practical nurse services to a Licensed Practical Nurse.

(5) Notwithstanding subsections (1) to (4), the direction to provide clinical nursing services may only be given by

  1. a registered nurse, a certified graduate nurse or a permit holder under the Nursing Profession Act,

  2. a registered member as defined in the Psychiatric Nurses Regulation (AR 509/87), or

  3. a physician.

In Saskatchewan, licensed practical nurses are governed under the Licensed Practical Nurses Act, SS 1993, c.L-14.1:

"practice as a licensed practical nurse" means the performance of health care services under the direction of a:

  1. duly qualified medical practitioner;

  2. registered nurse; or

  3. psychiatric nurse who is registered pursuant to The Psychiatric Nurses Act and whose registration is in good standing;

where the performance of those services requires the knowledge and skill of a person who qualifies for registration pursuant to section 18, but does not include those services that are prescribed by the Lieutenant Governor in Council.

Finally, the Manitoba Licensed Practical Nurses Act, RSM 1987, c. P100, defines the scope of practice of LPNs as follows:

"practical nursing" and "the practice of licensed practical nursing" means representing oneself as a licensed practical nurse who

  1. assists registered nurses in the care of acutely ill patients and rendering those services for which she has been trained,

  2. not being a registered nurse or a person in training to be a registered nurse, undertakes the care of patients under the direction of a medical practitioner or a registered nurse, and

  3. administers medication prescribed by a medical practitioner consistent with her training;




4.Responses to Consultation

Most of the responses are based on the scope of practice statement initially proposed by the LPNABC and the CLPNBC. Since there is some similarity between the initial submissions and the CLPNBC’s revised scope statement, the responses are set out here.

Several respondents, including Douglas College, University of Victoria (School of Nursing) (UVIC), and Manitoba Health suggest that the proposed scope statement is too broad, and some, such as the Ministry of Advanced Education, Training and Technology (MAETT, formerly Ministry of Education, Skills and Training), suggest that there is much overlap with the RN scope of practice.

Many respondents, including the BC Society of Occupational Therapists (BCSOT), the BC Dietitians’ and Nutritionists’ Association (BCDNA), the Greater Victoria Hospital Society (GVHS) and the University of British Columbia School of Nursing (UBC), criticize that part of the College's proposal which states that LPNs can practice independently when clients have a "well defined health challenge with predictable outcomes" but must practice in partnership when a condition is more complex. Several respondents state that LPNs do not have the expertise to distinguish a complex from a non-complex condition.

For example, in response to the initial submission, the Registered Nurses Association of BC (RNABC) states:

RNABC has a concern about the concept of "independence" as it is currently presented in the context of practice component of the proposed scope. It is accurate to state that as a regulated group, LPNs are independently accountable for their practice. This does not mean, however, that their preparation allows them to practice independently in every health care situation. There are clearly situations where it would be inappropriate for the LPN to practise independently as noted below.

The interpretation of the "independent" practice of LPNs is important because as the College points out, their competencies prepare them to provide nursing care to "clients with well-defined health challenges with predictable outcomes". The LPN is not educationally prepared to make the determination about the nature of the health care challenge and whether or not the outcomes are predictable. This requires more advanced assessment skills which are part of the competency profile of a registered nurse. Thus it is important that the scope of practice statement clearly reflect that the LPN practices independently within his/her scope once the complexity of the client's care needs including possible outcomes have been established in partnership with others.

In response to the revised scope statement, the RNABC states:

The scope of practice proposed by CLPNBC can be viewed as having two components: a definition of practice and a context of practice statement. The definition states that LPNs "provide professional nursing care and services to promote health and healing..." The context of practice component states that LPNs practice "independently and in partnership...to individuals, families and groups, in a variety of settings..."

RNABC therefore has substantial concern with the proposal to delete the following from the scope statement "where the client has a well defined health challenge with predictable outcomes the LPN may function independently. As the acuity or complexity of care increases and/or outcomes are not predictable and an advanced level of knowledge is required, the LPN must work in partnership with other health care professionals as an interdependent member of the team to meet the care needs of the client(s)."

UBC states:

We have specific concern in regard to the vagueness of wording in the [CLPNBC]statement that alluded to "well-defined health challenges with predictable outcomes". Our questions included the following:

  • Who will assess clients for referral to an LPN caregiver?

  • Who will monitor and evaluate that the assessments are accurate and made with the best interest of the client-rather than economic implications in mind?

  • Will employers have adequate understanding of nursing education curricula to be able to deploy caregivers, based not on their relative cost, but on the necessary knowledge, skills and values to meet the client's needs, and with attention to provision of adequate decision support for the provision of safe and appropriate care?

We suggest the addition of a clause addressing the issues of responsibility for defining "predictable outcomes" and "increasing complexity". The level of decision-making must not be driven entirely by economic factors, nor can it be left solely to the discretion of the employer or the LPN. Ambiguity in the current language leaves both the LPN and the client vulnerable.

In its submission the BC Nurses’ Union (BCNU) contends that the twelve-month general education of LPNs does not equip them in the same way as RNs who complete a three-year comprehensive educational program.

Some respondents questioned whether LPNs should be providing care to families, groups and communities. For example, the HEABC stated that group care situations require much more advanced knowledge and training than LPNs possess.

The College of Massage Therapists of BC (CMTBC) states that the proposed scope of practice statement is too long and confusing.

Several of the respondents to the consultation make the general point that it is important that the scope of practice statements for the three professions be sufficiently different in order to indicate the unique characteristics of each profession.

Douglas College comments that there is little differentiation between the three nursing bodies' proposals. Similarly, the Ministry of Advanced Education, Training and Technology (MAETT) states that it is difficult to differentiate the three categories, and therefore difficult to assess what educational preparation is required.

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

Responses to Proposal to Eliminate Supervision Requirement

The responses vary on the issue of whether the College’s proposal to remove the supervision requirement is appropriate. The BC Society of Occupational Therapists (BCSOT), the Para-Med Health Services and Vancouver Community College (VCC) support removal, while the Health Employers Association of BC (HEABC), the BC Medical Association (BCMA), the College of Psychologists of BC (CPBC) and UBC do not.

For example, the BCMA states:

The current Act requires that LPNs carry out all duties under the direction of a physician. The new proposal from the [CLPNBC] recommends that LPN’s work independently if they choose. This is of concern to us since the proposal suggests that such independence would be determined according to the ability of the LPN to work at an optimal level of competence vis-à-vis situations that may arise. Given this, any proposed change in the Act should continue to require that duties be carried out under the direction of a qualified physician.

The College of Psychologists of BC (CPBC) states:

In their proposals both groups have eliminated the requirement of 5 (1) of the proposed scope of practice of Licensed Practical Nurses under the Health Professions Act. This requirement "all nursing duties must, except in an emergency, be carried out under the direction of a medical practitioner who is attending the patient or under the supervision of a Registered Nurse who is rendering service to the patient," should be maintained. It is our understanding a practical nurse does not practice independently, but within the confines of a health care institution, such as a hospital or under the direction of a registered nurse or other health care professional. They may function without direct supervision.

In its April 30, 1998 submission, the CLPNBC states:

The term "supervision" is so poorly understood that it has been problematic in the practice setting and the professions would benefit from clear direction in that area. The situation often arises that a Registered Nurse who does not have a particular competency at the practice level, e.g. tracheostomy care, is supervising a Licensed Practical Nurse who not only has the competency for tach care but also has a post-basic specialty program in that area. This arises because the current legislated scope of practice of the LPN requires that supervision. Often it is assumed that a particular professional has a competency by virtue of their designation. The reserved acts model does not directly address that phenomenon which is common but will go a long way in identifying that when the Licensed Practical Nurse has the knowledge, skill, ability and judgement to carry out a reserved act the same baseline knowledge applied to the reserved act can be transferred to include similar components of care which are predicated on that same body of knowledge. It will assist in the appropriate utilization of nurses.




5.The Council's Conclusions

The current scope of practice for licensed practical nursing requires that all services be performed under the direction of a medical practitioner or under the supervision of a registered nurse. Virtually all of the provinces reviewed by the Council impose similar requirements. However, in Ontario, where the "controlled" or reserved acts model is in place, registered nursing assistants are not subject to any supervision requirement.

The College’s initial proposal stated that LPNs provide nursing care "independently or in partnership with other health care professionals/providers". While several respondents submitted that the supervision requirement ought to be maintained, others took a more flexible position. Though conceding that LPNs do practise independently in certain situations, others questioned whether LPNs had the training and education necessary to identify when independent practice is appropriate. The RNABC for example supports the removal of the supervision requirement but indicates that independent practice should be carefully circumscribed. Clearly, LPNs carry out some tasks independently and some under supervision but it is not easy to determine which tasks fall into which category.

Underlying the submissions favouring continuation of the supervision requirement is a concern that independent practice by LPNs would be unsafe. However, under the reserved acts model, only those acts which present a significant risk of harm are reserved to those professions which have the training and education necessary to perform them. The performance of non-reserved acts which fall within a profession's scope of practice is regulated by its College and the standards of practice. Therefore, there need not be a general supervision requirement applying to a profession's entire scope of practice. To the extent that supervision is an issue in regard to the College's proposed reserved acts, that issue will be addressed in the reserved acts section of this report.

The Council’s recommended scope of practice statement for LPNs is similar to that of RNs. However, that does not mean that LPNs and RNs have the same training and education or that they perform the same services. The College itself recognizes there is a distinction as it acknowledges that RNs have a higher level of knowledge and skill, and that RNs play a more "dominant" role in the treatment of patients. In its initial submission, the College stated that

As the acuity or complexity of care increases, and/or outcomes are not predictable and an advanced level of knowledge is required, the fully licensed practical nurse must work in partnership with other health care professionals as an interdependent member of the team to meet the care needs of the client(s).

In a July, 1999 letter to the Council, the College, in referring to the overlap amongst the nursing professions, states that the "actual differences lie in the levels and breadth of knowledge, skill and judgement as applied across the contexts of nursing practice for essentially the same professions."

The distinction between the two groups of nursing professionals is recognized in the scope statement and in the Council’s recommendations on reserved acts, discussed below. Further, as the College states, "LPNs are responsible and accountable for the care and services they provide to clients through their Standards of Practice, the Code of Ethics and other practice guidelines." An important part of this role is ensuring that its members practice within their level of competency, and that LPNs are provided with guidance to determine when services must be carried out as part of an "interdependent team".

Therefore, the Council recommends the following scope of practice statement for licensed practical nurses:

The practice of nursing by licensed practical nurses is the provision of health care for the promotion, maintenance and restoration of health; and the treatment and prevention of illness and injury, including assessment of health status and implementation of interventions.




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, the 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.

As the Council has noted, the purpose of the profession-specific reviews is to determine which parts of the list each profession will be granted.

1. Proposed Reserved Acts

In its initial submission, the LPNs, like the Registered Nurses Association of BC (RNABC) and the Registered Psychiatric Nurses Association of BC (RPNABC), took the position that rather than proposing specific reserved acts, they should receive an exemption from the reserved acts of other professions. This proposal elicited the greatest response, most of it negative. Several respondents noted that the proposal amounted to a request that LPNs be granted a similar scope of practice to that of medicine.

The Central Vancouver Island Regional Health Board (CVIRHB) states that it likes the exemption proposal, which it feels offers the necessary flexibility. Similarly, the Greater Victoria Hospital Society (GVHS) states that it supports the nursing proposal as it believes members are able to practice within their level of competency through the supports and controls of the profession.

In its 1998 revised submission, the CLPNBC requested a specific list of reserved acts, as follows:

  1. Making a (nursing) diagnosis identifying a 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

    2. procedures below the surface of a mucous membrane

    3. administering a substance by injection or inhalation

    4. putting an instrument,

      1. beyond the external ear canal
      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
      7. into an artificial opening into the body.

In its revised proposal the College did not request the reserved act of prescribing, compounding, dispensing or administering by any means a listed drug (#5 on the Council’s list). However, in a July, 1999 letter the College clarified that it had intended to request this act but had inadvertently omitted it from the proposal.

The CLPNBC submits that LPNs have graduated with the knowledge, skill, ability and judgment to carry out these reserved acts independently.

The CLPNBC also proposes that the following three reserved acts be granted to LPNs acting under the direct supervision of a health professional caring for the client. They are:

  1. Casting a fracture of a bone;
  2. Applying or ordering the application of a hazardous form of energy including electricity, magnetic resonance imaging, lithotripsy, laser and x-ray; and
  3. Allergy challenge testing of a kind in which a positive result of the test is a significant allergic response or allergy desensitizing treatment in which there is a significant allergic response.

The CLPNBC makes the following general statement regarding the reserved acts:

The determination of the reserved acts or portions of the reserved acts that a nurse should be competent to carry out depends on the level of their basic education and any post-basic work they have completed to give them additional knowledge and clinical competence. In nursing, it makes no difference whether the nurse is an LPN or an RN for the identified acts since the competence for a reserved act depends on the knowledge, skill, ability and judgement in a given context of practice. The context of practice, the Standards of Practice, the practice setting and any legal parameters will dictate who has the right to carry out a reserved act. There are LPNs who have had more experience, who have gained more knowledge and exhibit better judgement than a registered nurse in some aspects of care.

For each of its proposed reserved acts the CLPNBC gives examples of the types of procedures LPNs perform.




2.Responses to Revised Reserved Acts Proposal

The Registered Nurses Association of BC (RNABC) does not support the CLPNBC’s proposed reserved acts. It states:

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. Further, granting a reserved act to a profession does not mean that all members of the profession would carry out the reserved act. The expectation is that professionals must always practice within their scope of competence.

Given the two criteria stated above in interpretation of reserved acts, RNABC does not support CLPNABC’s request for LPNs to have authority for:

Performing the following physically invasive or physically manipulative acts:

(a) procedures on tissue below the dermis, procedures below the surface of a mucous membrane
(d) administering a substance by injection or inhalation
(e) putting an instrument beyond the ear canal; beyond the point in the nasal passages where they normally narrow; beyond the opening of the pharynx; beyond the opening of the urethra; beyond the labia majora; beyond the anal verge; and into an artificial opening into the body.

This does not mean that RNABC does not agree with LPNs carrying out some of the tasks and procedures associated with these reserved acts. In fact, preventing LPNs from doing so would create a significant barrier to meeting some patients' health care needs. What we are concerned with is that LPNs do not possess the necessary competencies to make independent decisions to initiate such procedures as inserting a urinary catheter, irrigating a wound and syringing an ear. RNABC takes this position because the LPN is not educationally prepared to make the determination about the nature of the health care challenge. Indeed, CLPNBC states that "further to the assessment, the status (stable, unstable) of the client will be established in consultation with other team members in order to develop the care plans and work toward optimum health of the client" and "complete care for the client would not be an independent function until after the status has been determined."

The RNs’ comments are based on the principle that reserved acts are granted to professions that have the training and education to both initiate and perform the act independently. Several other respondents made the similar point that LPNs do not practice independently (see pages 18 to 21, above). One can infer from these submissions that these respondents do not support granting any reserved acts to LPNs.

The Council proposes to deal with each of the proposed reserved acts in turn.

a. Making a Diagnosis

The CLPNBC states that LPNs gather data (assessment) and reach a clear and concise statement of the patient’s health status (nursing diagnosis). Further, it states:

Development of the nursing diagnosis is the responsibility of the entire team of nursing care providers and is not a static but rather a dynamic activity. Assessment of the patient is a continual process in which everyone caring for the patient has a role. The ongoing assessment will identify wen some of the diagnoses are outdated and when new ones are added. As the nurse most frequently at the bedside caring directly for the patient, the LPN gathers data on a continual basis. The LPN may be in a leadership role in continuing care areas where they are the only nurse. In an acute care setting where the LPN is a member of the team caring for the client the LPN remains competent to make nursing diagnosis and develop the plan of care but this will more likely be in collaboration with other health professionals caring for the client and reflective of the partnership role in care delivery.

In its Working Paper the Council discussed the distinction between assessment and diagnosis:

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.

The services described in the College’s submission constitute assessment, not diagnosis, and therefore this reserved act is not granted to LPNs.

b. Physically Invasive or Manipulative Procedures

(1) procedures on tissue below the dermis
(2) procedures below the surface of a mucous membrane

The CLPNBC states that LPNs have had the prerequisite knowledge and skill to perform these procedures since at least 1984 at the entry level and longer for some who graduated as RNs or came from a province or country where they achieved the competency level required.

The LPNs state that an example of this type of intervention would be sterile dressing changes. They state that "LPNs have anatomy and physiology, medical and surgical aseptic technique, the skin as a protective system, types of drainage from a wound and the significance of each, signs of infection or other complication, etc." Other examples of procedures below the dermis include administering substances by injection or inhalation which is addressed in more detail below.

The Council accepts that the performance of these services fall within the core competency of LPNs

(3) administering a substance by injection, inhalation, instillation or irrigation

The College states that "LPNs have had the content for administering a substance by inhalation in the pharmacology component of their education program since 1984." Further, in 1995 the competency for administering medication by subcutaneous injection was added most notably for insulin and heparin. The College also states that LPNs "have had the competence related to oral, topical, rectal, vaginal, eye, ear, nose, and throat, inhalation and tube feed medication administration in BC since 1984."

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

(4) 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) beyond the external ear canal

The CLPNBC states LPNs have achieved the competence level to carry out this reserved act since the inception of the program in 1984. An example of this type of procedure is "cleaning beyond the external ear canal or examining the ear with an otoscope."

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

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

The CLPNBC states that its members have the prerequisite knowledge and skill to perform this act although they may not have achieved clinical competence within the basic program in BC. It states that only LPNs from other Canadian jurisdictions, RNs who are duly registered or LPNs who have gained competence outside of the traditional hospital setting will have full competence at the clinical level. Inserting nasogastric tubes for feeding is an example of these procedures though the College acknowledges that in many clinical settings LPNs do not perform this procedure.

The Council accepts that LPNs sometimes perform these services but they are not part of the core competency of LPNs.

(iii) putting an instrument beyond the pharynx

The CLPNBC states the LPNs have had the competency at the clinical practice level for this reserved act for many years. Suctioning techniques above the pharynx and inserting airways are examples of these procedures. The CLPNBC states that is has received no complaints about LPNs performing these procedures.

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

(iv) putting an instrument beyond the opening of the urethra

The CLPNBC states that LPNs have had entry level competency for urinary catheterization for about 15 years. It further states that LPNs have knowledge of anatomy and physiology, the skill of urinary catheterization, medical and surgical asepsis, and common health challenges involving the genitourinary system.

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

(v) putting an instrument beyond the labia majora

The CLPNBC states that LPNs have had the competency to perform such services for many years, and that an example of such procedures is administration of vaginal ointments and creams requiring the insertion of an applicator.

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

(vi)putting an instrument beyond the anal verge

The CLPNBC states that LPNs have traditionally been the care providers who administer rectal enemas to patients. It states that LPNs have knowledge of the gastrointestinal system, anatomy and physiology, and administration of all types of enemas.

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

(vii) putting an instrument into an artificial opening into the body.

The CLPNBC states that LPNs care for patients with a variety of artificial openings such as colostomy, ileostomy and tracheostomy. It states that LPNs sometimes insert enemas for colostomy and ileostomy patients, and are involved in trach care including suctioning the trach and removing and cleaning the inner canula.

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

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

The College states:

Licensed Practical Nurses have had the competence related to oral, topical, rectal, vaginal, eye, ear, nose, and throat, inhalation and tube feed medication administration in BC since 1984 with the subcutaneous injections added in 1995. Many LPNs have expanded the competency of injections to include intramuscular and this is not difficult since they already have the essential components of injection administration routes and would need only to add the routes for intramuscular. As with any category of ‘Nurse’, not all nurses have all of the competencies required for all of the reserved acts.

They also state that LPNs administer medication, including narcotics through many routes including orally, vaginally, through inhalation and by intramuscular injection.

The Council accepts that the performance of these services generally fall within the core competency of LPNs. However, the Council is not satisfied, and the CLPNBC concedes, that administering substances by intramuscular injection or intravenously is within the core competency of LPNs.

3. The Council's Recommendations

The Council has carefully reviewed all of the information presented.

In its report on registered nursing, the Council states as follows:

[T]he 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 also stated that in order to be granted independent reserved acts, a profession must demonstrate that its members both initiate and perform any reserved act.

These general comments are equally applicable to the profession of nursing by LPNs. However, in the case of LPNs, the reserved acts that they perform are carried out as part of the health care team, and are not initiated by LPNs. The evidence does not indicate that LPNs have the training and education necessary to independently initiate any reserved acts.

Therefore, the reserved acts performed by LPNs are either performed on the order of an authorized health professional (usually an RN or a medical practitioner) or are delegated to LPNs.

The Council recommends that the following reserved acts be granted to licensed practical 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;

    2. Administering a substance by injection, inhalation, irrigation, or instillation;

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

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

      2. beyond the pharynx,

      3. beyond the opening of the urethra,

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

      5. beyond the anal verge, or

      6. 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.

Several of the reserved acts proposed by LPNs are not within the core competency of most LPNs and if performed are done under supervision. These include:

  1. Putting an instrument, had or finger(s) beyond the point in the nasal passages, where they normally narrow,

  2. allergy challenge testing,

  3. casting a fracture of a bone,

  4. ordering or applying the application of a hazardous form of energy.

These acts would fall within the Council’s guidelines for delegation.




C.     SUPERVISED ACTS

Neither the LPNABC nor the CLPNBC, in its original submission, identify any specific acts which may be performed by persons supervised by LPNs. However, the CLPNBC submits that selected components of the nursing care required by a client can be safely delegated by an LPN to other health care providers, family or other qualified individuals, as long as certain criteria are met when deciding whether the selected components can be delegated. In this regard, the CLPNBC relies on the position statement of the RNABC entitled Guidelines for Delegating Nursing Tasks and Procedures.

The Terms of Reference imply that the Council will, for each reserved act granted to licensed practical nursing, 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 the a regulatory body is in the best place 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.

Therefore 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.




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 LPNABC and the CLPNBC propose to maintain the current title protection, as stated within the Nurses (Licensed Practical) Act Regulations under the HPA, for the titles "Licensed Practical Nurse" or "L.P.N.". The CLPNBC also proposes that its members continue to be entitled to use the term "nurse". However, the CLPNBC proposes that the title "nurse" be granted to LPNs within the Nurses (Licensed Practical) Act Regulations instead of receiving their legal authority to use the title "nurse" from the Nurses (Registered) Act, as is currently the case.

In a May 1996 submission, the CLPNBC proposed that the title "practical nurse" be reserved. It states:

Recently it has come to our attention that there are facilities in B.C., both acute care and extended care, who are allowing individuals not currently licensed with the College as an LPN to use the title "PN". It is the belief of the College that these individuals are, knowingly or unknowingly, holding themselves out to their colleagues and to, the general public to be part of a regulated and monitored profession. This is increasingly apparent with registered nurses who are working as "practical nurses" or formerly licensed practical nurses who have either lapsed their license or had it removed through the discipline process.

There was very little comment on this part of the proposal other than expressions of general support.

The Council is satisfied that the current titles granted to LPNs are appropriate. In addition, the Council accepts the CLPNBC’s submission that unregulated use of the term "practical nurse" can be confusing to the public, and therefore that title and the initials "P.N." ought to be reserved to this profession.

Therefore, the Council recommends that the following titles be reserved for members of the profession:

  • Licensed Practical Nurse;
  • L.P.N.;
  • Practical Nurse; and
  • P.N.

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




E.     OTHER ISSUES

1. Abolition of Separate Nursing Professions

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.




IV.     RECOMMENDATIONS

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

    The practice of nursing by licensed practical nurses is the provision of health care for the promotion, maintenance and restoration of health; and the treatment and prevention of illness and injury, including assessment of health status and implementation of interventions.

  2. The Council recommends that the following reserved acts be granted to licensed practical 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;

      2. administering a substance by injection, inhalation, irrigation, or instillation;

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

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

        2. beyond the pharynx,

        3. beyond the opening of the urethra,

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

        5. beyond the anal verge, or

        6. 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 Schedule Act.

  3. The Council recommends that a provision be enacted which sets out the duties of ahealth 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.

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

    • Licensed Practical Nurse;
    • L.P.N.;
    • Practical Nurse; and
    • P.N.

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




APPENDIX   C
GLOSSARY AND ABBREVIATIONS OF NAMES

BC Dietitians’ and Nutritionists’ Association BCDNA
BC Medical Association BCMA
BC Nurses’ Union BCNU
BC Society of Occupational Therapists.BCSOT
Central Vancouver Island Regional Health Board CVIRHB
College of Licensed Practical Nurses of BC (formerly the BC Council of Licensed Practical Nurses)CLPNBC
College of Massage Therapists of BC CMTBC
College of Psychologists of BCCPBC
Greater Victoria Hospital SocietyGVHS
Health Employers Association of BCHEABC
Hospital Employees’ UnionHEU
Licensed Practical Nurses Association of BCLPNABC
Ministry of Advanced Education, Training and Technology (formerly Ministry of Education, Skills and Training)MAETT
Registered Nurses Association of BCRNABC
Registered Psychiatric Nurses Association of BCRPNABC
University of British Columbia (School of Nursing) UBC
University of Victoria (School of Nursing)UVIC
Vancouver Community CollegeVCC