Scope of Practice:Scope of Practice:Intra & Intra &

InterdisciplinaryInterdisciplinary

Ann Syme, RN, MSN, PhD studentAnn Syme, RN, MSN, PhD studentProvincial Program & Network Provincial Program & Network Director: Director: Pain & Symptom Pain & Symptom Management/Palliative CareManagement/Palliative CareBC Cancer AgencyBC Cancer Agency

Pharmacy Leadership Conference

2007

OverviewOverview

• Expansion of nursing’s scope of Expansion of nursing’s scope of

practicepractice

– Nurse anesthetistsNurse anesthetists

– Nurse endoscopistsNurse endoscopists

– Nurse practitionersNurse practitioners

• Intersection of the role of nursing and Intersection of the role of nursing and

pharmacy as the pharmacist’s role pharmacy as the pharmacist’s role

expandsexpands

Pharmacy Leadership Conference

2007

Disciplinary Scope of Disciplinary Scope of PracticePractice

• Metaparadigm for the nursing Metaparadigm for the nursing

discipline is comprised of four concepts discipline is comprised of four concepts

(Fawcett, 2005):(Fawcett, 2005):– Human beingsHuman beings

– EnvironmentEnvironment

– Health Health

– NursingNursing

• Also - caring, cultural competenceAlso - caring, cultural competence

Pharmacy Leadership Conference

2007

Pharmacy Leadership Conference

2007

Nurse PractitionersNurse PractitionersOne of two types of Advanced Practice NursesOne of two types of Advanced Practice Nurses

• CNS – RNs with Master’s or doctoral preparation CNS – RNs with Master’s or doctoral preparation

that specialize in an area of nursing practice by that specialize in an area of nursing practice by – area, such as emergencyarea, such as emergency– population, such as pediatricspopulation, such as pediatrics– disease, such as breast cancer. disease, such as breast cancer.

• provide direct care, expert consultation to nurses provide direct care, expert consultation to nurses and other care providers, and implement system and other care providers, and implement system changes to improve health care deliverychanges to improve health care delivery

• NP - RNs with advanced Master’s degree plus NP - RNs with advanced Master’s degree plus clinical training which enables them to diagnose clinical training which enables them to diagnose and treat health problems including prescribing and treat health problems including prescribing drugs. drugs.

Pharmacy Leadership Conference

2007

NP’s – History and NP’s – History and Current StateCurrent State

• The NP role has come and gone several times in The NP role has come and gone several times in Canada, beginning with a program at McMaster Canada, beginning with a program at McMaster University in Hamilton during the 1970s. University in Hamilton during the 1970s.

• It takes special legislation to create the NP in each It takes special legislation to create the NP in each jurisdiction but the concept is spreading and there jurisdiction but the concept is spreading and there are 900 licensed NPs across the country. are 900 licensed NPs across the country.

• In Ontario – NP’s reintroduced in the 1990’s as In Ontario – NP’s reintroduced in the 1990’s as Acute Care PractitionersAcute Care Practitioners

• In BC – NP’s reintroduced in early 2000 as In BC – NP’s reintroduced in early 2000 as Primary Care PractitionersPrimary Care Practitioners

• As discussed, specialization of the role is As discussed, specialization of the role is proceedingproceeding

Pharmacy Leadership Conference

2007

Barriers & Barriers & FacilitatorsFacilitators

• Attitudinal (intra- & Attitudinal (intra- & interdisciplinary)interdisciplinary)

• Accreditation & Accreditation & licensurelicensure

• LegislationLegislation• FundingFunding• TitleTitle• Skill limitationSkill limitation• Liability issuesLiability issues• Practice model Practice model

limitationlimitation

• Policies and Policies and legislationlegislation

• FundingFunding• Inclusive practice Inclusive practice

modelsmodels• EducationEducation• Evaluation and Evaluation and

measurement of measurement of outcomesoutcomes

• Human resource Human resource shortagesshortages

Pharmacy Leadership Conference

2007

NP’s - What they are and NP’s - What they are and are notare not

• What an NP is What an NP is NOTNOT – a physician a physician

extenderextender– a physician a physician

replacementreplacement

• What an NP ISWhat an NP IS – a Masters’ a Masters’

prepared nurse prepared nurse with advanced with advanced preparation in preparation in diagnostics and diagnostics and prescriptive prescriptive practices practices which which are grounded in are grounded in the discipline of the discipline of nursingnursing

Pharmacy Leadership Conference

2007

The NP at Cancer Care The NP at Cancer Care TransitionsTransitions

NP Care for BCCA Patients

Associated with a tumour group - particularly one where children likely to be affected (e.g. breast or

gyne)

Transitional from or to curative care – and/or orphaned or otherwise alienated from their primary

care team

Referral/Consults

Consult with GP

Referral to specialist

Referral to specialized service

(diabetes education, breast

health unit, palliative care)

Issues

Difficult induction into the cancer system

Difficult transition to survivorship

Complex symptom management

Palliative care

Stakeholders

Oncology teams

GP’s and other

primary care

providers

home care

Primary Care needsManagement of co morbid conditions/

disease

Increasing severity of symptoms/progression of

trajectory

Pharmacy Leadership Conference

2007

Nurse AnesthetistsNurse Anesthetists

• Began in USA Civil War and the Franco-Prussian Began in USA Civil War and the Franco-Prussian

WarWar

• 1919 - formally recognized in the US as the first 1919 - formally recognized in the US as the first

nursing specialtynursing specialty

• 1937 – claimed by the AMA but not taken up until 1937 – claimed by the AMA but not taken up until

the end of WWIIthe end of WWII

• ““turf” shared in the US – 60% of anesthesiology is turf” shared in the US – 60% of anesthesiology is

nurse delivered (up to 70-80% in rural areas) and nurse delivered (up to 70-80% in rural areas) and

in 11 other countries (MacDonald & Schreiber, in 11 other countries (MacDonald & Schreiber,

2003)2003)

Pharmacy Leadership Conference

2007

Nurse AnesthetistsNurse Anesthetists

• In Canada – MD anesthesiology is the In Canada – MD anesthesiology is the

most difficult to fill specialty positionmost difficult to fill specialty position

• Cost of one CRNA = 1/10 of MD (USA)Cost of one CRNA = 1/10 of MD (USA)

• Demonstrated equality in clinical Demonstrated equality in clinical

outcomesoutcomes

• Stemming from the Romanow Report, Stemming from the Romanow Report,

there is movement afoot in Canada to there is movement afoot in Canada to

develop this role as a specialty NP roledevelop this role as a specialty NP role

Pharmacy Leadership Conference

2007

Endoscopic NursesEndoscopic Nurses

• With the national push for colorectal cancer With the national push for colorectal cancer

screening, the need for nurse endoscopists is screening, the need for nurse endoscopists is

being investigatedbeing investigated

• Studies show equality in rate of complication & Studies show equality in rate of complication &

accuracy between NP(E) & gastroenterologists accuracy between NP(E) & gastroenterologists

(Wallace et al, 1999) and greater efficiency and (Wallace et al, 1999) and greater efficiency and

effectiveness between NP & FP (Schoenfeld et effectiveness between NP & FP (Schoenfeld et

al, 1999)al, 1999)

• If developed, would come under a specialized NPIf developed, would come under a specialized NP

Pharmacy Leadership Conference

2007

Examples Where RN’s work Examples Where RN’s work with Pharmacist’s with with Pharmacist’s with

Expanded RolesExpanded Roles• Palliative carePalliative care• Inpatient clinical consultationInpatient clinical consultation• Community primary care Community primary care

– nurses employed by pharmacies - S. Africanurses employed by pharmacies - S. Africa– Infusion programs (USA and Canada)Infusion programs (USA and Canada)– PhwSIs - consult on diabetes, chronic disease, PhwSIs - consult on diabetes, chronic disease,

sexual health (UK)sexual health (UK)• Oncology careOncology care• EducationEducation

– Nurse curriculum re: pharmacologyNurse curriculum re: pharmacology– UBC Interprofessional team education : AIDs UBC Interprofessional team education : AIDs

and Palliative Careand Palliative Care

Pharmacy Leadership Conference

2007

Pros & ConsPros & Cons

• Creates better access Creates better access to care, more pt-to care, more pt-centredcentred

• Care planning is Care planning is more comprehensivemore comprehensive

• Pharmacists are more Pharmacists are more “in touch” with “in touch” with patientspatients

• Nurses can share the Nurses can share the burden of burden of pharmacological carepharmacological care

• Pharmacists have Pharmacists have limitations toolimitations too

• Not everybody Not everybody needs every team needs every team member alwaysmember always

• Potential for role Potential for role overlap and role overlap and role conflict – need to conflict – need to manage the manage the relationshiprelationship

Pharmacy Leadership Conference

2007

Patient &

Family

Ph RN MD SW