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THE SCOPE OF NURSING PRACTICE:

A REVIEW OFISSUES AND TRENDS

October 1993

© Canadian Nurses Association

50 DrivewayOttawa, Ontario

K2P 1E2

ISBN 1-55119-083-4

All rights reserved. No part of this book may be reproduced in any manner withoutwritten permission of the Canadian Nurses Association.

Can you, as nurses, evolve a health-care system

in which you relate not only to your rolein the system, but also

in which you relate to the broad changesin your society now taking place?

Nobody has done that yet.If you, as a group, could do that,

you would provide someleadership for the

country.

—Dr. Fraser Mustard,in an address to the

National Nursing Symposium,Winnipeg, Manitoba

November 1990

i

CONTENTS

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

BACKGROUND: WHY IS NURSING SCOPE OF PRACTICE A KEYCONCERN? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Pressures to Clarify Nursing Scope of Practice . . . . . . . . . . . . . . . . . 3The Context: New Directions in Health Care . . . . . . . . . . . . . . . . . . 4Nursing: A Profession in Transition . . . . . . . . . . . . . . . . . . . . . . . . . 6

NURSING REGULATION AND SCOPE OF PRACTICE: Definitions and Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Current Nursing Scope of Practice Definitions

and Approaches in Canada . . . . . . . . . . . . . . . . . . . . . . . . 12Work in Progress to Clarify Scope of Practice

in Canadian Jurisdictions . . . . . . . . . . . . . . . . . . . . . . . . . . 14Nursing Scope of Practice Approaches in Other Countries . . . . . . . 14

ISSUES SURROUNDING SCOPE OF NURSING PRACTICE INCANADA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

The Role of the Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17The Need to Clearly Define Nursing Practice . . . . . . . . . . . . . . . . . . 18Expanded Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Overlaps and Shared Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Consistent Application of Scope of Practice . . . . . . . . . . . . . . . . . . 24

WHAT LIES AHEAD? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

APPENDIX A: THEMES OF PRIMARY HEALTH CARE . . . . . . . . . . . 31

APPENDIX B: THE SCOPE OF NURSING PRACTICE: A Summary of Issues and Trends in the Provinces and Territories of Canada. 1993. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

APPENDIX C: INTERNATIONAL INFORMATION ON NURSINGPRACTICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

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INTRODUCTION

This paper presents an overview of the current situation and emerging directionsregarding nursing scope of practice in Canada. Information is also included to helpplace the Canadian situation within the international context.

The paper was prepared in response to requests from the Canadian NursesAssociation's member organizations for assistance and support in addressing thiscomplex topic. The paper is intended to provide a basis for discussion, debate,collaboration and action by various organizations concerned with nursing regulationand practice. As well as nursing associations, it may be useful to other healthprofessional organizations, educational organizations, health policy makers andplanners. The paper:

— describes the current legislation, definitions and approaches to scope of practicein Canada;

— presents key scope of practice issues; and

— identifies trends and directions which are emerging to address theissues—within Canada and internationally.

The information and analysis in the paper is based on: data and publications fromCNA's member organizations in each province and territory; a review of theliterature; and a review of international approaches, issues and developments.Appendix A presents a summary of the input from provinces and territories.

This paper isintended toprovide abasis fordiscussion,debate,collaborationand action.

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BACKGROUNDWHY IS NURSING SCOPE OF PRACTICE A KEYCONCERN?

A profession's scope of practice encompasses the activities its practitioners areeducated and authorized to perform. The overall scope of practice for theprofession sets the outer limits of practice for all practitioners. The actual scope ofpractice of individual practitioners is influenced by the settings in which theypractice, the requirements of the employer and the needs of their patients or clients.Although it can be difficult to define precisely, scope of practice is importantbecause it is the base from which governing bodies prepare standards of practice,educational institutions prepare curricula, and employers prepare job descriptions.Consumers, too, need at least a general understanding of scope of practice to knowwho is qualified to provide different kinds of services.

PRESSURES TO CLARIFY NURSING SCOPE OFPRACTICE

All of CNA's member associations report they are experiencing pressure fromnumerous sources to clarify the scope of nursing practice. The main source ofpressure is nurses themselves, who see the rapid changes taking place in the healthsystem resulting in a need to re-examine the role of the nurse.

Other groups of health care workers involved in nursing care are also pushing forrole clarification. Nursing assistants and licensed practical nurses, in particular,believe they have been restricted in practice because of poor understanding of theirroles and the scope of their practice. Those who collaborate with or whose practiceoverlaps with nursing are also seeking role clarification vis-à-vis boundary issues.Social workers, physicians, and podiatrists are some of the other professional groupsmost concerned about this.

Scope ofpractice isimportantbecause it isthe basefrom whichgoverningbodiespreparestandards ofpractice,educationalinstitutionspreparecurricula,andemployersprepare jobdescriptions.

Background: Why is Nursing Scope of Practice a Key Concern?

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Governments and other employers want the roles of various provider groups inhealth care to be clearly defined, and the areas of exclusive practice to bereviewed. Their goal is to ensure that the most appropriate mix of providers isgiving care in the most cost-effective way, and that unnecessary turf-guardingis not negatively affecting cost and quality of health care. Consumers are anothersource of pressure as they question what the role of the nurse will be in achanging health care system.

THE CONTEXT: NEW DIRECTIONS IN HEALTH CARE

Cost-effectivehealth caremeans ensuringthe right serviceis efficientlyprovided at theright time, in theright place, bythe mostappropriate andleast expensivemix of healthcare providers.

The pressures to clarify and better define the scope of nursing practice arestrongly affected by the significant changes taking place in Canada's health caresystem. These new directions in health care have three key themes which areforcing a reconsideration of the scope of nursing practice.

Need for More Cost-effective Use of Resources, Created by RisingCostsHealth expenditures in Canada are increasing faster than population growth andfaster than inflation. We spend more than $60 billion a year on health, about$2,470 for each person. In spite of escalating costs, more physicians, morenurses, more hospital beds and increased technology, there is no evidence thatCanadians are any healthier. In fact, there is some evidence to the contrary(Barer & Stoddart, 1991; Rachlis & Kushner, 1989). There is wide agreementthat if we can get better value for our health care dollars, further increasesshould not be needed. Pressures to clarify nursing scope of practice are part ofthis drive to improve cost-effectiveness, in order to maintain universal access tohigh quality health care.

Cost-effective health care means ensuring the right service is efficiently providedat the right time, in the right place, by the most appropriate and least expensivemix of health care providers. Health human resource planning, which addressesthis last point, has become a key focus for improving cost-effectiveness. Theconcentration on the role of all health care providers by governments and otherstakeholder groups has created an environment in which nursing and other healthcare professionals must be able to describe what they do, why it is important forthis to be done and why they should do it rather than somebody else.

The publication in 1991 of the document Toward Integrated Medical ResourcePolicies for Canada, prepared by Morris L. Barer and Greg L. Stoddart for theFederal/Provincial/Territorial Conference of Deputy Ministers of Health,concentrated attention on nursing as an appropriate and cost-effective alternativeprovider of certain kinds of health services. Although the report focused onphysician resource management, it raised many issues pertaining to the scope ofnursing practice, especially the issue of overlaps and shared practice. Barer andStoddart also noted the problems that ensue from the double standard of scopesof practice, which allows for the expansion and contraction of nursing practicedepending upon whether or not physicians are available. One of the conclusionsof the report was that health professions cannot be discussed in isolation sincescopes of practice inevitably overlap. Health human resource planning mustfocus on achieving the most cost-effective mix of different types of providers.

The Scope of Nursing Practice: A Review of Issues and Trends

4

Nurses havebeen at theforefront in

advocating for,developing and

applying newmethods to

maintain andpromote health

and preventillness.

Health human resources will continue to be an area of close scrutiny. Crichton,Hsu and Tsang (1990) note that nurses are one of the dominant healthprofessional groups because of their numbers. They believe the key question is:"How should registered nurses work together with physicians, allied healthprofessionals and less qualified nursing staff in the labor market situation?" (p.77). Finding the answer to this question is crucial and CNA is engaged in anumber of activities to analyze existing health human resource planningframeworks. Discussions with other national associations of allied healthprofessionals and Employment and Immigration Canada are in progress todevelop an integrated framework which can be used to predict futurerequirements for health care professionals.

Another key focus in the drive to improve cost-effectiveness and ensure qualityof care is better evaluation of the costs and benefits of existing and newtreatments, drugs and technologies. Although the emphasis so far has primarilybeen on expensive new drugs and technologies, nursing will increasingly be askedto demonstrate the cost-effectiveness of its interventions. This brings into playmany of the questions and issues surrounding nursing scope of practice.

Increased emphasis on health promotion, health maintenance andillness preventionThere is ample evidence that spending more on the treatment of illness will notmake us a nation of healthier people. It is increasingly clear that devoting moreof our attention and resources to promoting and maintaining health for individuals,families and communities should result in a healthier population and less need forillness care. The federal/provincial/territorial ministers and deputy ministers ofhealth have stated their intent to place greater emphasis on these strategies, toachieve a more balanced and effective health system.

Nurses have been at the forefront in advocating for, developing and applying newmethods to maintain and promote health and prevent illness. CNA's advocacyfor health care reform based on primary health care (PHC) philosophy andprinciples (see for example CNA, 1988) is also part of the move away from asystem totally dominated by medical treatment. One of the key themes of PHCis entry to the health system through a variety of primary-contact healthprofessionals, including nurses. (Appendix A presents the ten themes that wouldcharacterize a PHC system, in the view of CNA). The shift to primary healthcare, health promotion and disease prevention creates opportunities for uniqueand independent roles for nurses, and at the same time raises a number of issuesregarding the scope of nursing practice.

Shift from institutional to community careCanada is over-reliant on institutional care for the chronically or terminally ill andthose who require continuing care because of physical disabilities, mental illnessor other functional limitations. Research shows community and home care is acost-effective alternative to long term institutional care, if the patient's needs arewell matched with the type and setting of care. And it results in greaterindependence and a better quality of life for the client. There is also evidencethat more of the acute care now provided in hospitals could be delivered morecost-effectively in community and home settings. In all parts of Canada, thereare actions underway to achieve a more appropriate balance betweeninstitutional and community based care.


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The trend to care in community and home care settings is creating new demandsand different roles for nurses, the majority of whom (approximately 70%) arenow employed in hospital settings. At the same time, the shift to community careis resulting in higher levels of acuity in hospital settings, creating greater demandsfor nurses in specialized and expert roles. These changes are driving a numberof the current issues surrounding scope of nursing practice.

Nursing has beenburdened with

societalexpectations of

selflessness anddevotion, the

status problemsof traditionalfemale work,

historicaldomination byphysicians andoppression by

hospitals.

NURSING: A PROFESSION IN TRANSITION

Nursing is a relatively young profession which is maturing and evolving. Therapidly developing and changing nature of the profession is a key pressure drivingthe ongoing debate on scope of nursing practice. At the same time, thepressures created by the themes of health care system change described aboveare accelerating and complicating this natural process of nursing's professionalmaturation.

The history of nursing in Canada points both to the problems confronting nursingas well as to the many accomplishments (Growe, 1991). Nurses in Canada haveachieved status as an independent profession with an exclusive right to practicewhich is protected in law (Morris, 1991). There have been significant gains indefining the future educational expectations and requirements for nurses, withconsiderable progress toward the goal of a bachelors degree for entry to theprofession by the year 2000. And nursing organizations, with leadership fromCNA, have ensured that the key role of the nurse in maintaining affordable, highquality health care receives a high profile in the ongoing debate about the futureof Canada's health care system.

However, the relative powerlessness, uncertain professional identity and lack ofrecognition for the value of nursing work continue to be realities. This has acrucial effect on the current debate about scope of nursing practice. Nursing hasbeen burdened with societal expectations of selflessness and devotion, the statusproblems of traditional female work, historical domination by physicians andoppression by hospitals, where nurses were kept in training schools long afterstudents preparing for other occupations had moved into colleges and universities(Crichton, et al. 1990). According to Monique Bégin, a former federal healthminister, "nurses are under-appreciated and underpaid because most of them arewomen". (The Vancouver Sun, 10 November 1992).

While the physical tasks of caring that nurses provide are taken for granted aspart of "women's work", the knowledge base of nursing and nurses' professionaljudgment and skills as decision makers and problem solvers in the provision ofcare are largely invisible—to clients and often to other health care providers.Some of the confusion around the question "What is nursing?' arises from thisinvisibility of a significant part of nursing practice.

Changes in society are inevitably having an impact on nursing. Baumgart andLarsen (1992) discuss some of the key influences. "A widely recognized and far-reaching factor affecting the future of nursing practice in Canada is the changingsocial structure of the Canadian population" (p. 98). The aging of the populationis creating a shift in focus from acute illness to chronic degenerative conditions.


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Changes in family patterns, such as the smaller size of families, more personsliving alone and greater participation of women in the paid work force, are allfactors affecting the delivery of health care and nursing practice. Another factoris the increasingly multicultural nature of Canada's population. Because healthpractices and care are so embedded in culture, understanding cultural diversityis essential for the practice of nursing, especially in urban areas. The consumermovement has pressured all health care professionals to become more responsiveto the needs of the community and the client. The increase in self-care andindependent living for individuals who might previously have been hospitalized arechallenges for health care, and particularly for nursing practice.

Baumgart and Larsen also show how nursing practice is being markedly alteredby factors such as new technology, the aging of the population, and the "wellness"revolution. Chronic, degenerative diseases and the search for more cost-effective methods of care are creating opportunities for nurses to develop moreindependent and autonomous clinical roles. With these opportunities, nurses inpractice are experiencing stresses and dilemmas that arise out of the squeeze onhealth care resources and the expectation that they should continue to do all theirtraditional jobs while taking on new roles and responsibilities.

Some key trends within the nursing field which contribute to the pressures toclarify the scope of nursing practice are:

— Expansion of nursing roles. Throughout their careers nurses developexpertise through education, experience, research and the development ofskills in response to the context of their work setting. Because nursesprovide the coordination and care for many different kinds of clients, fromneonates to entire communities, many different kinds of expertise develop.Baumgart and Larsen (1992) believe that "new practice opportunities areopening for nurses and will continue to do so throughout the 1990s."However, nurses who have developed expanded expertise in counseling,midwifery, therapeutic touch or alternative therapies, to name just a few ofthe many possibilities, are often confronted with the question "is thisnursing?" The question also arises when nursing practice expands into areastraditionally viewed as medical services. While there may be some commonunderstanding of what the core of nursing is, the spreading out from thatcore finds nurses at different places in their own professional developmentand understanding of the depth and breadth of nursing practice. This createsa need for a definition of scope of nursing practice that is sufficiently broadand flexible to enable appropriate expansion of nursing practice, and at thesame time provide a reasonable degree of direction on the boundaries of thediscipline.


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— Increasing clinical specialization. Nursing practice roles are becomingmore differentiated and clinical specialization is now well established. Thenumbers of and demand for clinical nurse specialists (CNS), nurses witheducational preparation at the masters level or beyond, is growing. Thenumber of nursing specialty areas is also expanding. These nurses providedirect nursing care, and also educate and consult with other nursing staff anddo research. Calkin (1992) notes that "demands for 'specialists' have arisenin many types of organizations, including those delivering health care. A lookat advertisements for nurses indicates that almost as many employers askspecifically for nurses for positions in 'specialty areas' such as critical care,operating room, psychiatric, gerontology, orthopedics, trauma nursing service,emergency, neurology/ neurosurgery, maternal/child, pediatrics, specialtymedical/surgical, or intensive care as ask for 'general duty nurses.' Someemployers offer bonuses for work in specialty areas, especially if the nursehas had further study in the area. As well, specialization is often associatedwith credentialing in the form of certification" (p. 327). CNA established aNational Certification Program in 1986 to recognize competence to practicein a nursing specialty. This program also encourages the refinement ofnursing roles and documents various nursing specialties, thereby contributingto the evolution of nursing science. The increasing specialization of nursingcreates pressures to ensure that scope of practice definitions appropriatelyenable specialized practice. There is pressure in some jurisdictions toestablish separate scope of practice statements for particular nursingspecialties, while others feel this would unnecessarily fragment the disciplineof nursing.

— Increasing interest in independent practice. At present, the majority ofnurses in Canada are employed in hospitals, but this is a fairly recent trendwhich began after World War II. Before that time, the majority of nurseswere employed by families to provide nursing services in the home. Privateduty nursing was the "primary field of employment for 60% of registerednurses in the 1930s and continued as a prominent choice of work until thelate 1940s" (Baumgart and Wheeler, 1992, p. 56). There is now a small butgrowing trend for nurses to establish independent practice outside ofhospitals and to offer a variety of nursing services in the domains of clinicalpractice, education, research and administration. Many of these nurse"entrepreneurs" are providing care in alternative ways or settings, forexample, counseling, health promotion services, foot care, support to breast-feeding mothers, and care in the home. Others are using their criticalthinking and interpersonal relationship skills to consult with and assistorganizations and groups.

These trends and the increasing complexity of the nursing field often createstress and role strain. This partly results from the many and varied expecta-tions placed upon the nurse to expand or contract nursing practice based on theneeds of the setting or facility, the availability of physicians and other healthpractitioners, time of day and geographic location. Most nurses can describe thefrustration of assuming the roles and tasks of many other professional and non-professional groups when those groups are unavailable. With the current budget


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cuts, nurses are increasingly being asked to perform work previously done byothers. One nurse described nursing care in her setting as "...chaotic andfragmented because the needs of different disciplines were driving it. Ratherthan directing patient care, nursing was adjusting to the needs of psychiatry,psychology, dietary, physical therapy, pharmacy, and activity therapy" (Kerr,1990, p. 6). Nurses do not believe that having a more clearly delineated anddefined scope of practice would totally resolve these types of problems, but theyfeel it would make a significant contribution.

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NURSING REGULATION AND SCOPE OFPRACTICE: DEFINITIONS AND APPROACHES

Nursing exists in response to a need in society, so there is an inherent obligation toprotect and be accountable to the public. It is for the purpose of protecting societythat professions are regulated and their scope of practice designated by law. Ifthere were no danger of harm, there would be no need for regulation of activities inthe domain of a professional.

Risk (1992) notes that "definitions of scope of practice may be broad, allowing thepractitioner to act to the limit of his or her judgment and ability, or restrictive, relatingto specific procedures" (p. 370). In Canada, as in virtually all western industrialcountries, nursing is regulated by professional legislation which defines, describesand controls the practice of nursing. Nursing, as a profession, has the privilege ofself-regulation. This means certain responsibilities for regulation are granted to aprofessional body by the legislation. In Canada, this responsibility usually resideswith the provincial or territorial nursing associations, to whom responsibility isdelegated for setting standards for entrance to, and practice of, the profession.

Since the legal definition of nursing practice is usually quite general, the professionalorganization's interpretation of the definition and its establishment of standards ofpractice is critical, since these standards play an important part in the understandingof nursing, both from a legal perspective and from a community perspective.Because times change and nursing practice is continually evolving, the regularupdating of the standards and statements of nursing organizations which elucidatenursing practice is essential.

It is the legal definition of nursing practice included in professional legislation thatestablishes basis for the scope of practice in which a registered nurse may engage.As Wiebe (1992) points out, "this definition is important in that it is frequently usedby employers and insurers to describe the limits of employee duties and of insurance

Practicingoutside thescope ofpractice mayentitle theemployer todenyresponsibility for thenurse, theinsurer todenycoverage forthe nurse,and theprofessionalassociationto takedisciplinaryactionagainst thenurse.


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coverage. Practicing outside the scope of practice may entitle the employer todeny responsibility for the nurse, the insurer to deny coverage for the nurse, andthe professional association to take disciplinary action against the nurse". Shewarns that "venturing outside the scope of professional nursing practice (i.e., asoccurs in the preparation and dispensing of medications) is fraught with risk oflegal liability, particularly as this may involve nurses engaged in activities beyondtheir education and competence" (p. 277).

CURRENT NURSING SCOPE OF PRACTICEDEFINITIONS AND APPROACHES IN CANADA

In Canada,professional

legislation is theresponsibility ofthe provincial or

territorialgovernment.

In Canada, professional legislation is the responsibility of the provincial orterritorial government. Although each province and territory has taken asomewhat different approach to how it deals with nursing practice in itsprofessional legislation, there are also significant similarities. As noted above, itis this legal definition which is the basis for the scope of practice of nurses in theprovince. Appendix B presents the legal definition of nursing practice, excerptedfrom the nursing legislation of each jurisdiction.

Some provinces (Alberta, British Columbia, Quebec and soon Ontario) havelegislated scopes of practice that specifically empower nurses to deliver healthcare services/functions to others. In these cases, the act specifies the types ofservices/functions that are included, for example: promoting, maintaining orrestoring health; coordinating health care; and teaching nursing theory orpractice. There is considerable similarity between provinces in the functionsincluded. The other jurisdictions simply define nursing practice in their legislation,except the Northwest Territories, which does not define nursing but protects thetitle "registered nurse". These definitions of nursing typically include a list offunctions similar to those used by provinces that specifically legislate the scopeof practice. The legislation of all jurisdictions includes protection of title, butsome protect the title "nurse", while others protect the title "registered nurse".

British Columbia, Alberta and Nova Scotia include an element in their legislationthat helps clarify what nursing practice is, relative to the practice of other healthcare disciplines. They do this by making reference to "application of professionalnursing knowledge" as the basis for performance of the functions that arelisted in the definition of nursing practice. It seems likely that more jurisdictionswill adopt this approach over time.

The way nursing practice is legally defined in all jurisdictions is quite broad, andprovides very few restrictions on practice (and as a result, also provides littlespecific direction). The professional nursing bodies specify the details of howthese broad definitions are interpreted and applied. Historically, this has beendone by listing the tasks and procedures performed by nurses. There isincreasing agreement that the boundary of nursing practice cannot be determinedonly by listing tasks and rules that are often incomplete and soon outdated. Pastreliance on this approach has contributed to the lack of clarity and agreementabout the scope of nursing practice we face today.

Nursing Regulation and Scope of Practice: Definitions and Approaches

11

The Alberta Association of Registered Nurses (AARN) (1992) recently issueda scope of practice document that provides a very clear example of a newapproach. It establishes broad goals/principles for nursing and recognizes acontinuum ranging from basic to advanced nursing practice, as well as acontinuum of educational preparation, from basic to advanced. It then specifiesareas in which nurses work to meet their clients' needs for care (e.g. food/fluids,hygiene, relief of pain); areas where nurses work with individuals, families,groups and communities on broader health concerns (e.g. health promotion orhealthy environments; and roles the nurse fulfills (e.g. caregiver, teacher). TheAARN believes this approach will provide maximum scope and flexibility torespond to changing nursing practice. At the same time, it provides a clear basiswhich nurses and others can use to make decisions about whether particularpractice requirements of particular work settings are within the scope of nursingpractice.

Scope of practice documents recently published or under development by nursingassociations in other provinces are also moving away from lists of tasks andprocedures and toward similar enabling approaches based on principles. Thedirections being taken by national nursing bodies in the U.K. and U.S., describedon page 14, are also moving toward this broad, enabling approach to definingscope of practice.

The province of Ontario has recently implemented a new model for scope ofpractice which is unlike that of any other Canadian jurisdiction. Schwartz (1989)in the Blueprint for the Regulation of Ontario's Health Professions describesa new system "...based on the principle that the sole purpose of regulation is toprotect the public interest not to raise any profession's economic power or toraise its status." In the old system, some health professions were licensed (theirmembers have an exclusive license or monopoly over the provision of servicesthat fall within their scope of practice) and others were registered (theirmembers have the exclusive right to use certain titles). This situation "... doesnot effectively protect the public from unqualified health care providers. As well,it has undesirable effects on the health care system. In particular, it inhibitsinnovation in the way various health professions can be utilized, making it moredifficult to provide the best service at the lowest cost" (p. 3). The new approachlicenses acts rather than professions . In the past, all the Health Disciplines Actprofessions except nursing were "licensed".

The Ontario model consists of three main elements. These are a generalstatement describing the profession's scope of practice which includes what theprofession does, the methods it uses, and the purpose for which it does it; a listingof all potentially harmful acts and procedures which are controlled (licensed)acts; and provisions to provide a safety net to catch any residual harm. This lastelement is aimed at unqualified caregivers who cause harm, or a risk of harm,without actually performing any licensed act. The Medicine Act sets out thewhole list of controlled acts, and the Nursing Act outlines certain controlled actsthat nursing is authorized to perform.


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Under this model the authority to designate areas of scope of practice will shiftaway from the small number of licensed professions, of which the most dominantis medicine and "... will be more equally shared by all the health professions,while ultimate authority will reside with the Government" (Schwartz, p. 16).

WORK IN PROGRESS TO CLARIFY SCOPE OFPRACTICE IN CANADIAN JURISDICTIONS

There are manyinitiatives taking

place acrossCanada to better

describe,classify, and

evaluate nursingpractice.

Clarifying nursing scope of practice requires the profession to more clearlydefine what nursing practice entails. There are many initiatives taking placeacross Canada to better describe, classify, and evaluate nursing practice. At thenational level, for example, CNA hosted the Nursing Minimum Data Set(NMDS) Conference in 1992 "to develop in Canada a standardized format forpurposes of ensuring entry, accessibility and retrievability of nursing data."(CNA, 1993, p. 12). This is a significant contribution to describing nursingpractice in consistent terms, which is an essential condition for developing auseful scope of practice definition.

At the provincial and territorial level, there is also a great deal of activity toclarify the nature and scope of nursing practice. Several jurisdictions haverecently completed, or are in the process of developing, broad scope of practicedocuments. As well, there are a number of reviews and documents inpreparation that address more specific questions such as expanded roles, transferof function, and the role of the RN within the discipline of nursing. Initiatives ineach jurisdiction are summarized in Appendix B. Some of the initiatives are alsopresented at various points in the remainder of this paper, to illustrate or clarifyneeds and issues raised by the nursing associations.

NURSING SCOPE OF PRACTICE APPROACHES INOTHER COUNTRIES

The discussion related to scope of nursing practice is not unique to Canada.Around the world, nurses are struggling with the same questions we are askingin Canada. What is the scope of nursing practice? Is it restricting orenabling? Dr. Margretta Styles (1991) has characterized the imminent 21stcentury as "the century heralded by many as the International Century." Stylesbelieves we are approaching a new political and economic world order, "a globalcommunity made up of regions within which there will be free trade and freemigration of workers across national boundaries and in which political disputesmay well be settled by international judiciaries or multi-national coalitions"(p. 354). It is because of this global direction that the pressures upon nursing andthe challenges this creates are international in scope.

Regulation of nursing is a major focus of the International Council of Nurses(ICN). Fadwa A. Affara, director of ICN's regulation of nursing project, hopesthat the nursing profession in all countries will mobilize to achieve the type ofregulatory controls necessary to confront the demands of increasingly complexhealth care services. This should lead to development of regulatory practices

Nursing Regulation and Scope of Practice: Definitions and Approaches

13

and policies that will have as one of their purposes the clarification of thestructure, accountability and scope of practice of the profession. As part of theICN process of helping national nurses associations examine and develop theirregulatory practices, Affara and Styles (1992) have developed a usefulpublication entitled Nursing Regulation Guidebook: From Principle toPower. (The ICN definition of nursing practice is included in Appendix C.)

The approachesto nursing scopeof practice beingtaken by the UK

and the USillustrate an

emergingapproach that

could helpCanada clarifythe direction itwishes to take.

The approaches to nursing scope of practice being taken by the national nursesassociations in the United Kingdom and the United States illustrate an emergingapproach that could help Canada clarify the direction it wishes to take for thefuture. The approach defines scope of practice with broad enabling principlesor statements which describe the essence of nursing practice.

In the United Kingdom, nursing's Central Council (UKCC) recently publishedThe Scope of Professional Practice (1992) which "emphasizes the nurse'sprofessional accountability and places decisions about boundaries of practice inthe hands of the individual practitioner." The following six principles establishguidelines to help practitioners make these decisions. Appendix C provides moredetails about the nature and scope of nursing practice in the U.K.

" The registered nurse, midwife or health visitor:— must be satisfied that each aspect of practice is directed to meeting the needs

and serving the interests of the patient or client;— must endeavour always to achieve, maintain and develop knowledge, skill and

competence to respond to those needs and interests;— must honestly acknowledge any limits of personal knowledge and skill and

take steps to remedy any relevant deficits in order effectively and appropriatelyto meet the needs of patients and clients;

— must ensure that any enlargement or adjustment of the scope of personalprofessional practice must be achieved without compromising or fragmentingexisting aspects of professional practice and care and that the requirements ofthe Council's Code of Professional Conduct are satisfied throughout the wholearea of practice;

— must recognise and honour the direct or indirect personal accountability bornefor all aspects of professional practice; and

— must, in serving the interests of patients and clients and the wider interests ofsociety, avoid any inappropriate delegation to others which compromise thoseinterests."

In the U.K., the previous system of extended role certificates was based on atask-oriented approach to nursing and focused on the activities delegated tonursing by medicine. It was intended to guarantee that nurses who carried outthese tasks were competent to do so. Two problems provided pressure forchange. First, the extended role certificates tended to be institution-based,sometimes even ward or unit-based, and therefore not transferable. It alsoworked against comprehensive team-based holistic care. The UKCC documentgives the framework for determining adjustments to the future scope of practice."It provides the process to maximise the scope of practice while at the same timesafeguarding care to all patients and clients....In consultation with othercolleagues, these principles should enable nurses, midwives and health visitors todemolish artificial and unhelpful barriers to their practice" (Moores, 1992, p. 28-29).


14

In the United States, control of the practice of nursing is similar to that inCanada. The State Nursing Practice Act (SNPA) of each state describesnursing practice and the scope of that nursing practice. The professional nursingassociation of the state enlarges the definition of that description.

The title "Nurse" includes all nurses: nurses aides, nurse practitioners, registerednurses, etc. Some SNPAs have a definition section. Many states define the practiceof registered nursing as "diagnosing and treating human responses to actual orpotential health problems through such services as case finding, health teaching,health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens prescribed by a licensed physician." Certainterms such as diagnosing and treating are sometimes further defined.

As in Canada, the legal definition of other occupations, medicine in particular,also affects nursing scope of practice in the U.S. For example, most medical practiceacts define the practice of medicine as "diagnosing, treating, operating orprescribing for any human disease, pain, injury, deformity or physical condition".In some medical practice acts nurses are listed among those exempt from needinga license to practice medicine if they are "operating in each particular case under thespecific direction of a regularly licensed physician or surgeon." (Northrop, 1989, p.104)

The American Nurses Association (ANA) takes the position that definition of thescope of nursing practice flows out of nursing process, that is, the process ofassessment, decision-making and action that all nursing practice follows. In thedocument The Single Scope of Clinical Nursing Practice, the ANA states thatthe core or essence of nursing practice "is the nursing diagnosis and treatmentof human responses to health and to illness. This core of the clinical practice ofnursing is dynamic, and evolves as patterns of human responses amenable tonursing intervention are identified, nursing diagnoses are formulated andclassified, nursing skills and patterns of intervention are made more explicit, andpatient outcomes responsive to nursing intervention are evaluated " (ANA, 1987).

This definition of the scope of nursing practice relies heavily on nursing diagnosis.The authors acknowledge the potential legal problems in this regard, given thatthe legislation often does not distinguish clearly between medical and nursingdiagnosis. "Obviously, making nursing diagnoses can be risky under a law thatpermits them without clearly defining them. ... Because the language of nursepractice acts is so broad, in many instances a decision on whether certain nursingconduct is a violation must be based on analysis of whether that conduct wasintended to be included within conduct permitted by the act." (Nurse's ReferenceLibrary, 1984, p. 15)

15

The essential issue is the need to answer such questions as "What is nursing?""What does the nurse do that is unique?" or "What is the role of the nurse?"And these questions must be answered in a way that is sufficiently broad andflexible to enable the full range of nursing practice, and at the same timeprovide reasonable direction on appropriate boundaries for the profession.

ISSUES SURROUNDING SCOPE OF NURSINGPRACTICE IN CANADA

Provincial and territorial nursing associations identified scope of practice questionsand issues that fall into three broad categories: the role of the nurse; shared practiceand overlaps with other groups providing nursing services and with other health caredisciplines; and the need for more consistency in the way nursing scope of practiceis articulated in different circumstances and settings. These issues, and approachesthat are emerging to address them, are discussed below. The specific issues raisedby each jurisdiction are presented in Appendix B.

THE ROLE OF THE NURSE

Every provincial and territorial nursing association identified questions and issuesregarding the appropriate role of the nurse, both in the overall health care systemand within the discipline of nursing.

The broad term "role of the nurse", as used in the above question, seems to besynonymous with the description of scope of practice presented earlier in the paper(i.e. the activities nurses are educated and authorized to perform, as establishedthrough legislated definitions of nursing practice complemented by standards,guidelines and policy positions issued by professional nursing bodies).


16

For purposes of this paper, the term "scope of practice" rather than "role of thenurse" is used to describe this broad concept. In fact, asking the question "Whatis nursing?" or "What is the role of the nurse?" is really asking "What is thescope of nursing practice?"

While many use the term "role" in the broad fashion described above, role(s) ofthe nurse is also commonly used to refer to particular areas or categories ofpractice within the overall scope of nursing practice. For example, nurses mayhave roles as direct service providers, educators, managers, researchers, patientadvocates, etc. Most of the specific questions and debate about nursing scopeof practice within the discipline focus on the role of the nurse as direct providerof clinical services—in various settings. Yet there is also a concern that theother roles of nurses must be given a higher profile and more recognition ascrucial aspects of the discipline. An approach to defining nursing practice thatclearly enables and supports the existing wide range of nursing roles, and at thesame time allows for emerging new roles, is needed.

"If we cannotname it, we

cannot control it,finance it,

research it, teachit, or put it into

public policy. It'sjust that blunt!"

The scope of practice issues regarding the "role of the nurse" identified byprovincial and territorial nursing associations seem to group into two areas: thosethat concern the definition of nursing practice in a broad way; and those thatfocus more specifically on expanded nursing practice. These are discussedseparately in the following two sections.

THE NEED TO CLEARLY DEFINE NURSINGPRACTICE

Defining nursing practice in a way that recognizes and responds to the trends andpressures described earlier in this paper is clearly one of the most significantchallenges facing nursing associations in all provinces and territories of Canada.This problem is a universal one (Affara & Styles, 1992), so it comes as nosurprise that every Canadian jurisdiction is struggling with the seemingly simplequestions posed above.

Styles (1991) believes that, to clarify its scope of practice, nursing must be ableto precisely and concisely describe:

— the clinical problems nursing addresses;— its interventions with respect to those problems;— the scientific basis for those interventions; and— the outcomes of nursing interventions.

Styles quotes Norma Lang, who has effectively posed the classification challengefor the profession, "If we cannot name it, we cannot control it, finance it,research it, teach it, or put it into public policy. It's just that blunt!" (p. 357). Atthe same time, this classification challenge must be met in a way that does notinappropriately limit nursing practice or prevent it from adapting to the rapidchanges that are occurring.

Issues Surrounding Scope of Nursing Practice in Canada

17

As noted earlier in this paper, there is a move away from using lists of tasks andprocedures as the primary method of describing the practice of nursing. Theemerging new direction takes a broad, enabling approach to defining scope ofpractice. This direction is increasingly being adopted by professional nursingbodies in Canada, as well as in the U.K. and the U.S,

As professional nursing associations move away from the traditional approachand toward new models for defining and describing nursing practice, there willbe a period of transition that is inevitable. The global trend toward reciprocallicensing of professionals and ease of movement across borders (Styles, 1991),as well as the potential implications of the North American Free TradeAgreement, may necessitate consistency in regulatory practices in the future.As noted earlier in the paper, every nursing association in Canada is engaged inactive examination of the issues surrounding regulation and scope of nursingpractice. This intense activity is producing valuable resources for movementthrough the transition.

Some provincial associations have recently published documents that reflect thetrend away from defining nursing in terms of tasks. Examples are the RegisteredNurses Association of British Columbia document Appropriate Use of ARegistered Nurse's Knowledge and Skill: A framework for decision making(1990), the Alberta Association of Registered Nurses document Scope ofNursing Practice (1992); the Saskatchewan Registered Nurses Associationdocument The Registered Nurse Scope of Practice: Guidelines for DecisionMaking and Delegation (1992) and the Nurses Association of New Brunswickdocument The Role of the Nurse (1993). Other jurisdictions seem likely tofollow this trend in the scope of practice documents they are now developing.

To clarify what the profession as a whole expects of its members, many nursingassociations have also recently revised their standards, or are planning to do so.Some of this work is moving in the direction of providing principles to guidedecision making, rather than lists of tasks and directives. One example is theRegistered Nurses Association of British Columbia document Standards forNursing Practice in British Columbia (1992). It presents broad statementsabout professional nursing practice that give guidance and direction which "maybe used as a reference to describe 'reasonable' and 'prudent' practice" (p. 1),without unnecessarily limiting practice. These statements are followed byindicators which serve as examples of activities that demonstrate how thestandard can be applied and are not intended to be an exhaustive list. This modelis very interesting because it grounds the expectations of nursing practice inbeliefs about the attributes of a profession.

This emerging approach to describing nursing scope of practice recognizes thatit will never be possible to define, precisely and in great detail, which activitiesare inside and which are outside the boundaries of nursing. This is partlybecause the "state of the art" of health care and nursing are changing so rapidlythat such lists become outdated almost before they are completed, and partlybecause the field has become far too complex to be reduced to lists of tasks andprocedures. As the nursing profession matures and the body of nursing


18

knowledge expands, it will become easier to clearly describe the principles,models and functions that are the basis of nursing. As this happens, it willbecome clearer whether the new approach, which is based on nursing principlesand models, will provide the necessary balance between breadth and flexibilityto enable the full range of nursing practice, and reasonable direction onappropriate boundaries for the profession.

EXPANDED ROLES

The trend toward expansion of nursing roles described earlier (see "Nursing: AProfession in Transition p.7) is creating a number of issues related to scope ofpractice. The concept of a continuum of nursing practice from "novice to expert"is helpful in understanding some of the questions that arise. This continuum hasbeen described by Benner (1984) as including the stages of novice, advancedbeginner, competent, proficient, and expert. The expecta-tions of clinicalpractice must recognize the transition from novice to expert that takes placethroughout the career of a nurse and allow for the full scope of practice of theexpert nurse. It is sometimes argued that nursing's scope of practice could orshould be expanded, when in fact what is required is to fully utilize the scope ofnursing practice that actually exists at the expert end of the continuum. Thechallenge is to define scope of practice in a way that does not limit advanced orexpert practice. The new approach for defining scope of practice describedabove has excellent potential to avoid such limitation.

Given the current economic realities, the issue of expanded nursing roles is at theforefront of efforts to improve cost-effectiveness of health care, as demonstratedby pressure to use the nurse in physician extender or physician replacementroles. The utilization of the full scope of nursing practice may be theappropriate response to the demand for expanded roles. In the vision of nursingwhich CNA promotes, it is very clear that nurses offer another way of providingcare and have a unique contribution to make to the health of Canadians. Basingindividual responsibility and accountability on the nurse's education, experienceand skills is certainly congruent with professional conduct. The expert nurse'sadvanced practice may look very much like some of the activities of physicians,but that does not mean it is not nursing practice.

Since the publication of Barer and Stoddart's (1991) report, there has been muchattention to their discussion of the "expanded duty nurse" as an alternate providerof some services traditionally viewed as medical services. Midwifery and thenurse practitioner are two of the best examples of extended nursing roles whichoverlap with medicine in this way. They are also areas that have beenextensively researched and proven cost-effective and efficacious in providingquality care and high patient satisfaction (see CNA, The Nurse Practitioner,1993). There are also other examples such as nurses working in the north, whohave for many years capably provided a range of health care services thatoverlap with medicine.


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There is some pressure from inside and outside nursing to ensure that definitionsof scope of nursing practice clearly enable the practice of nurse practitioners.The argument can be made that many or most of the services offered by nursepractitioners fall into the category of primary health care, and clearly should bewithin the scope of nursing practice. On the other hand, some nurses fear thatexpanding the practice of nursing into areas which overlap with medicine willincreasingly place nurses in the role of "physician-extender", thus harming thepotential of nursing practice to make a significant contribution in its own right toa cost-effective, high quality health care system. As yet there is no clearresolution to this debate in sight. However, the trend toward defining nursingpractice in terms of nursing knowledge and nursing principles will likely bring asolution that enables nurses to practice in a wide range of roles, some of whichwill inevitably overlap with other professions.

OVERLAPS AND SHARED ROLES

As nursingconsiders these

issues, it must beclear that the

focus is on safeand qualified

care that meetsclient's needs,

not on jobs andterritory.

Closely related to the issues and trends discussed in the immediately precedingsection are questions about overlaps and shared roles among professional groupswithin the nursing discipline, and overlaps with other disciplines. More than halfof the provincial and territorial nursing associations identified such issues as beingamong their most significant concerns. Phrases typically used to describe theissue included "the role of the RN within the discipline of nursing," "the issue ofoverlaps," "transfer of function and delegation," "delegation of nursing tasks," and"the performance of nursing tasks by non-professionals."

In the health care field as in any other, there will inevitably be continuingquestions about the boundaries between the various professions and groupsworking in the field. These arise and evolve over time, driven by such factorsas new technology, educational requirements, supply and demand for variouspractitioners and skills, and fiscal realities. The health care delivery system is nota static environment, and responsibility for addressing issues of overlap in theface of constant change is the joint responsibility of the regulatory andprofessional bodies of the various health disciplines. Collaboration among thesebodies is necessary to provide guidance to all their members, and to ensure publicsafety.

When professional groups discuss their unique contribution to health care, andespecially when they disagree with other health care providers regarding scopeof practice issues, these discussions may appear to be territorial rather thanissues of safe and cost-effective practice. As nursing considers these issues, itmust be clear that the focus is on safe and qualified care that meets client'sneeds, not on jobs and territory.

Although some of the questions and trends are similar when considering overlapswithin the nursing discipline vs. overlaps with other disciplines, the differencesare sufficiently great that discussing them separately is useful.


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Overlaps Within NursingThe practice of nursing is so broad and varied that an element of role confusionis almost inevitable. As well as registered nurses, a variety of auxiliary healthcare personnel fall under the category of "nursing" in most facilities, for examplenursing assistants, aides, orderlies, etc.

Because nursing tasks are commonly shared by more than one group, it is oftena specific, exclusive task (such as the administration of medications) whichappears to distinguish the nurse from auxiliary groups. This is an erroneous andmisleading approach. The roles and responsibilities related to the coordinationand management of care within the scope of nursing practice distinguishes thepractice of the registered nurse from an auxiliary worker, not a specific task. Asindicated in earlier sections of this paper, a task-based approach to nursingdefinition has not proven satisfactory, and is being replaced with new, moreenabling models based on principles and guidelines for decision making.

Many physical aspects of care can be carried out either by registered nurses,nursing assistants, health care aides, family caregivers or volunteers. The keyquestion is the role each one plays while performing the task. When providingdirect nursing care, the nurse is making an assessment of the patient's condition,mobility and response to treatment as well as planning the care and services thatthe patient will need. The contact time is also used for teaching and counseling.The complexity and extent of the critical thinking, judgment and interpersonalskills involved in a seemingly simple physical task is not always visible orunderstood. It is often difficult for others to differentiate the role of registerednurses from that of nursing assistants when they both carry out some of thesame physical tasks. The challenge is to determine those aspects of nursing carewhich can be safely and appropriately done by others. As registered nurses takenew activities into their scope of practice, including those which were previouslyin the medical domain, they must be willing to give up activities which can safelybe carried out by other personnel. Nurses cannot and should not do it all.

Nursing organizations in most provinces and territories have recently publishedor are preparing documents to address overlaps within the discipline of nursing.The kind of enabling approach based on principles and guidelines describedabove is clearly evident in this work, although there is still some reliance on thelisting of tasks as the way of differentiating the practice of different groups.

The Association of Nurses of Prince Edward Island (ANPEI) has been studyingthe issues of overlapping practice between levels of nursing personnel since thelate 1980s. ANPEI takes the position that nursing must examine itself carefullyto determine which nursing tasks can be safely and effectively delegated toothers and which tasks should be done by nurses. The Association of RegisteredNurses of Newfoundland (ARNN) is carrying out a "skill mix" study to obtainmuch needed information on the roles of the registered nurse and registerednursing assistant. The Saskatchewan Registered Nurses Association (SRNA)provides guidelines for decision making about use of licensed and unlicensedauxiliary health care workers in The Registered Nurse Scope of Practice:Guidelines for Decision-Making and Delegation (1992). The Registered


21

Nurses Association of British Columbia (RNABC) is concerned with situationswhere some tasks associated with nursing care are being performed by unpaidand paid non-professionals, and will soon issue a revised position statement toprovide guidance on this. The RNABC is also studying the role of the RN inrelation to the role of the Licensed Practical Nurse and the RegisteredPsychiatric Nurse.

Overlaps with Other DisciplinesOverlaps between the boundaries of various health care disciplines have been aparticular issue for the discipline of nursing, because nursing practice is so broad.Its boundaries have historically expanded and contracted based on the supply anddemand situation in other disciplines, particularly medicine. Styles points out thatthe boundaries of scopes of practice are functionally, philosophically andpolitically determined (1986, cited by Risk, 1992). The boundaries are rarelyclear lines. The practice of medicine has been a licensed and protectedmonopoly over a certain area of practice everywhere in Canada, and thereforeis one of the main boundaries that affects nursing.

Because medicaland nursing

practice ischanging so

quickly, there isa continual need

to ensure thatstandards andguidelines for

transfer offunction arecurrent and

appropriate.

In jurisdictions where governments legislate the scope of practice for medicinerather than leaving it to the medical association to define, it tends to be describedas the diagnosis and treatment of disease, including operating, prescribingmedication, etc. (Morris, 1991). The legislation of all provinces and territoriesallows for delegation of certain "medical acts" to other health care professionals.Delegation of medical acts (also referred to as transfer of function) to nursinghas been a key aspect of nursing and medical practice for many years, andissues surrounding which medical acts can and should be delegated continue tobe a concern to most provincial and territorial nursing associations.

Professional nursing bodies, in collaboration with medical associations, havedeveloped standards and guidelines for delegation of medical acts. Some veryrecent examples are the Manitoba Association of Registered Nurses (MARN)document Transfer of Clinical Function to the Registered Nurse (1992),which outlines guidelines and assumptions which serve as a basis for policydevelopment and identifies the main responsibilities of the key stakeholders whenfunctions are being transferred from medicine to nursing. The NursesAssociation of New Brunswick document (NANB) Decision Making inNursing Practice (1992) provides general criteria for delegation, and thenexhaustively lists those functions which are advanced nursing competencies,those which are delegated medical functions, and those which cannot bedelegated from medicine.

Because medical and nursing practice is changing so quickly, driven by newtechnological developments to a considerable extent, there is a continual need toensure that standards and guidelines for transfer of function are current andappropriate. This becomes very cumbersome when the process consists oflisting specific tasks that may be delegated. As well, the nursing profession isbeginning to ask whether the concept of delegation of function is becomingobsolete. This is partly because the approach doesn't respond well to rapidchange, and partly because it doesn't sufficiently acknowledge that nursing is


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maturing to the point where it clearly controls its own body of knowledge andscope of practice.

Some argue that it should be possible to determine, on the basis of scope ofpractice definitions, whether most functions are primarily a medical function ora nursing function, and then place the function where it fits best. Some functionscould be acknowledged as shared functions. These would appear in both scopesof practice, with decisions about which profession would provide the functionbeing dependent on the client's needs and the circumstances or setting ofpractice. Principles and guidelines could be developed to guide such decisions.

Functions move from one discipline to another as technology, educationalrequirements and clinical practice change. For example, the thermometer andthe sphygmomanometer once belonged within the exclusive scope of practice ofthe physician. It may be possible for functions to move from one discipline toanother, without going through the stage of being a delegated function.However, this would require appropriate principles and mechanisms to guide theprocess. Such an approach could apply not just between medicine and nursing,but between all health care disciplines.

CONSISTENT APPLICATION OF SCOPE OFPRACTICE

Some of the provincial and territorial nursing associations are concerned aboutthe significant degree of variability in the way nursing scope of practice isapplied, depending on the geographic location or setting in which the nurse ispracticing. For example, the accepted and expected scope of practice of thenurse in the north or in an isolated outpost is quite different than the nurseemployed in an urban setting. Nurses working in remote settings often wonderwhy they are deemed capable of certain functions in that setting, but are notconsidered capable of the very same function or task when they return to thecity. At the same time, they wonder if their practice in the remote setting is safeand legal. To a lesser, but still significant extent, there are also differencesbetween the accepted scope of practice between community-based and hospital-based nursing.

It is to be expected that different settings will have different practicerequirements. The nurse is usually an employee of an organization thatdetermines the parameters of practice, within the overall scope of practiceestablished by the nursing body. The actual practice of individual nurses inparticular settings and organizations should be expected to vary across all of thevarious functions included in the full scope of nursing practice, and across the full"novice to expert" continuum. However, it is inappropriate and unacceptable ifa particular function or task is judged to be safely within nursing scope ofpractice when it is convenient or necessary because of resource availability (e.g.lack of physicians), but not within the scope of practice under othercircumstances.


23

Clearly defining nursing scope of practice, using the kind of enabling approachbased on principles to guide decision-making that is described earlier in thisdocument, should provide the foundation for resolving this issue. If the functionor task in question is judged by the nurse and her professional body to fall withinthe scope of nursing practice, then the nurse should be able to practice thatfunction in any setting or organization which has a need for it, provided she hasthe necessary competence. Inevitably, there will be areas of practice that areshared with other disciplines. Principles and mechanisms that provide aneffective process for decision making about which practitioner is the most cost-effective provider of the function will be needed to handle these situations.

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WHAT LIES AHEAD?

The pressures and trends described in this paper will certainly continue for theremainder of this and well into the next century. Continuing change is a reality forCanada's health system. By playing a leadership role in shaping that change, theCanadian Nurses Association and its member organizations are helping assure thefuture of universally accessible high quality health care for Canadians. Respondingeffectively to the many issues surrounding scope of nursing practice will be anecessary part of that leadership role. The initiatives already underway are animpressive beginning, and are setting a direction that recognizes the need forflexibility in the face of change, as well as the importance of cooperation andcollaboration among health disciplines.

It seems clear that the new directions in the health care system will providesignificant opportunities for nursing. Far from reducing and downgrading the roleof the nurse, as some had feared, changes such as the restructuring of health caredelivery and the emergence of new technologies are expanding the opportunities forthe practice of nursing. Many nursing jobs will be different, but nursing will continueto be a crucial part of the health care system.

The growing focus on primary health care and health promotion is a major factor inthis expansion into new nursing roles. CNA recognizes that "new definitions ofhealth roles, new modalities of health-care delivery and upgrading of educationsystems for health professionals" will be necessary for the shift in orientation tohealth and health promotion (1988, p. 7). Nursing has historically had a strongpresence in health promotion and primary health care, and is well positioned tofurther expand its practice in these areas. This is recognized by the fact that everyCanadian jurisdiction which defines nursing in its professional legislation nowexplicitly includes at least one and sometimes a combination of the functions ofpromoting health, maintaining health and preventing disease in the scope of practice.

Manynursing jobswill bedifferent, butnursing willcontinue tobe a crucialpart of thehealth caresystem.


25

Nursing in hospital settings is also being strongly influenced by restructuring inthe health care system. There is no doubt that the changes occurring in thissector will continue to be a particularly strong source of pressure on nursing torefine its scope of practice, and to resolve issues of overlap and shared practicewithin the discipline of nursing and with other health disciplines. The emergingapproaches for defining scope of practice discussed in this paper offer thebreadth and flexibility needed to respond to the growing complexity of nursingand the changing demands created by a rapidly evolving health care system—inthe hospital and all other health care sectors. The challenge now is to furtherexplore and test these new approaches.

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REFERENCES

Affara, F.A. & Styles, M.M. (1992). Nursing regulation guidebook: Fromprinciple to power. Geneva: International Council of Nurses.

Alberta Association of Registered Nurses (1992). Scope of nursing practice.Edmonton: Author.

American Nurses' Association (1987). The scope of nursing practice. KansasCity: Author.

Barer, M. & Stoddart, G. (1991). Toward integrated medical resource policiesfor Canada: Background document. Report prepared for theFederal/Provincial/ Territorial Conference of Deputy Ministers of Health.

Baumgart, A. & Larsen, J. (1992). Overview: Nursing practice in Canada. In A.Baumgart & J. Larsen (Eds.), Canadian nursing faces the future (p. 97-109).Scarborough: Mosby-Year Book Inc.

Baumgart, A. & Wheeler, M. (1992). The nursing work force in Canada. In A.Baumgart & J. Larsen (Eds.), Canadian nursing faces the future (p. 45-70).Scarborough: Mosby-Year Book Inc.

Benner, P. (1984). From novice to expert: Excellence and power in clinicalnursing practice. Menlo Park: Addison-Wesley.

Calkin, J.D. (1992). Specialization issues. In A. Baumgart & J. Larsen (Eds.),Canadian nursing faces the future (p. 327-342). Scarborough: Mosby-YearBook Inc.

Canadian Nurses Association (1993). Papers from the nursing minimum data setconference. 27-29 October 1992. Edmonton, Alberta . Ottawa: Author.

References

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Canadian Nurses Association (1988). Health for all Canadians: A call forhealth care reform. Ottawa: Author.

Canadian Nurses Association (1993). The Nurse Practitioner. Ottawa:Author.

Crichton, A., Hsu, D., & Tsang, S. (1990). Canada's health care system: Itsfunding and organization. Ottawa: Canadian Hospital Association Press.

Growe, S.J. (1991). Who cares? The crisis in Canadian nursing. Toronto:The Canadian Publishers.

Kerr, N.J. (1990). Whose practice is it anyway? Perspectives in psychiatriccare, 26(3), 5-6.

Manitoba Association of Registered Nurses (1992). Transfer of clinicalfunction to the registered nurse. Winnipeg: Author.

Moores, Y. (1992). Setting new boundaries. Nursing Times, 88(37), 29.

Morris, J.J. (1991). Canadian nurses and the law. Vancouver: ButterworthsCanada Ltd.

Northrop, C.E. (1989). The nursing shortage and nursing's legal scope ofpractice. Nursing Outlook , 37(2), 104.

Nurses Association of New Brunswick (1992). Decision making in nursingpractice. Fredericton: Author.

Nurses Association of New Brunswick (1993). The role of the nurse.Fredericton: Author

Nurse's Reference Library (1984). Practices, legal risks, ethics, humanrelations, career management. Springhouse: Springhouse Corporation.

Rachlis, M. & Kushner, C. (1989). Second opinion: What's wrong withCanada's health-care system and how to fix it. Toronto: CollinsPublishers.

Risk, M. (1992). Regulatory issues. In A. Baumgart & J. Larsen (Eds.),Canadian nursing faces the future (p. 365-379). Scarborough: Mosby-Year Book Inc.

Registered Nurses Association of British Columbia (1990). Appropriate use ofa registered nurse's knowledge and skill: A framework for decision-making. Vancouver: Author.

Registered Nurses Association of British Columbia (1992). Standards fornursing practice in British Columbia . Vancouver: Author.


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Saskatchewan Registered Nurses Association (1992). The registered nursescope of practice: Guidelines for decision-making and delegation.Regina: Author.

Schwartz, A.M. (1989). Striking a new balance: A blueprint for theregulation of Ontario's health professions. Recommendations of theHealth Professions Legislation Review. Toronto: Ontario Ministry ofHealth.

Styles, M.M. (1991). Bridging the gap between competence and excellence.ANNA journal, 18(4), 353-366.

United Kingdom Central Council for Nursing, Midwifery and Health Visiting(1992). The scope of professional practice. London: Author.

Wiebe, S.D. (1992). Legal Issues. In A. Baumgart & J. Larsen (Eds.),Canadian nursing faces the future (p. 273-292). Scarborough: Mosby-Year Book Inc.

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APPENDIX ATHEMES OF PRIMARY HEALTH CARE

In 1988, the Canadian Nurses Association articulated its vision of Health CareReform, envisioning a health care delivery system founded on primary health care(PHC) philosophy and principles. This system would encompass ten themes:

— Equal access to optimum health status and to comprehensive, continuous healthcare regardless of gender, culture, income level, language, education, maritalstatus, age

— Equal entry into the system through a variety of primary-contact healthprofessionals

— Equitable distribution of health care professionals in rural and urban areas,northern and southern regions of Canada, and in tertiary care and extendedcare positions

— Equal emphasis in government documents and health care budgets on the fourfacets of PHC: health promotion, illness prevention, illness care andrehabilitation at individual, familial, aggregate and community levels

— Equal emphasis in generic university educational programs for healthprofessionals on the four service delivery components of PHC

— Equal recognition of experiential knowledge associated with individualconsumers, families, friends, volunteers, indigenous helpers, and self-help/mutualaid groups and of professional knowledge, by providers and government

— Equal emphasis in professional educational institutions and service agencies onpartner, consultant, referral, advocate and educator roles along with traditionalcaregiver roles (This assumes a new partner role for laypersons and lay groups)


30

— Mechanisms for interagency linkages and for provincial governmentinterdepartmental linkages to plan for and institute PHC

— Interdisciplinary education of health professional students regarding PHC asthe norm rather than the exception. In the practice sphere, interdisciplinarycontinuing education, forums and research on PHC receive preferentialstatus and funding

— Community health/multiservice centres serve as the centre of local healthcare delivery rather than tertiary care institutions. This would be associatedwith a shift in emphasis from high-technology to low-technology.

(CNA: Health for all Canadians, 1988)

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APPENDIX BTHE SCOPE OF NURSING PRACTICE: A SUMMARY OF ISSUES AND TRENDS IN THE PROVINCES ANDTERRITORIES OF CANADA. 1993.

In the summer of 1992, CNA collected information on the scope of nursing practicefrom the provincial and territorial nursing associations which are memberassociations of CNA. The legal definitions of nursing practice in every province orterritory has been excerpted from the legislation and is also included.

Each association provided information on the work taking place within theirjurisdiction. This input included publications of completed projects or statements, aswell as a discussion of the work planned and in progress. An attempt was made tocapture all the related work which addresses the scope of nursing practice includingthat which focuses on the role of the nurse. The member associations also identifiedtheir key issues related to this topic as well as the sources of pressure to have scopeof practice defined. This material has been summarized into the following appendix.

In 1993, the jurisdictions reviewed and updated the information. Because ofOntario's unique situation, the College of Nurses of Ontario (CNO) also reviewedthe Ontario section. Their contributions are included in this compilation of material.

CNA'S ASSOCIATION MEMBERS

RNABC Registered Nurses Association of British ColumbiaAARN Alberta Association of Registered Nurses AssociationSRNA Saskatchewan Registered Nurses AssociationMARN Manitoba Association of Registered NursesRNAO Registered Nurses Association of OntarioNANB Nurses Association of New BrunswickRNANS Registered Nurses Association of Nova ScotiaANPEI Association of Nurses of Prince Edward IslandARNN Association of Registered Nurses of NewfoundlandNWTRNA Northwest Territories Registered Nurses AssociationYRNA Yukon Registered Nurses Association

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APPENDIX CINTERNATIONAL INFORMATION ON NURSINGPRACTICE

INTERNATIONAL COUNCIL OF NURSES

The International Council of Nurses in 1987 defined nursing as:

Nursing, as an integral part of the health care system, encompasses thepromotion of health, prevention of illness, and care of physically ill, mentally ill,and disabled people of all ages, in all health care and other community settings.Within this broad spectrum of health care, the phenomenon of particularconcern to nurses is individual, family and group "response to actual or potentialhealth problems". These human responses range broadly from health restoringreactions to an individual episode of illness to the development of policy inpromoting the long-term health of a population.

The unique function of nurses in caring for individuals, sick or well, is to assesstheir responses to their health status and to assist them in the performance ofthose activities contributing to health, recovery, or to dignified death, that theywould perform unaided if they had the necessary strength, will, or knowledgeand to do this in such a way as to help them gain full or partial independence asrapidly as possible. Within the total health care environment, nurses share withother health professionals and those in other sectors of public service thefunctions of planning, implementation, and evaluation to ensure the adequacy ofthe health system for promoting health, preventing illness, and caring for ill anddisabled people.

International Council of Nurses. Minutes of the Meeting of the Councilof National Representatives, 10-14 August 1987, Auckland, New Zealand.Agenda Item 8.3 (p. 8)

Appendix C: International Information on Nursing Practice

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THE UNITED KINGDOM

The Royal College of Nursing (1991) has defined the nature and scope of nursingpractice:

Nursing is a professional discipline complementary to other health careprofessions. Its purpose is to help people adopt a healthy lifestyle, to enablepeople to cope with their health problems and to care for people duringillness in ways which promote health and healing and minimise disability.The practice of nursing requires specialist knowledge and skills, a humaneconcern for others and the exercise of clinical judgement.

Nurses contribute to health care within a multidisciplinary team. They areindividually accountable for their actions and practise within a statutoryregulatory framework established to protect the public and assure the qualityof nursing services.

The role of the nurse is constantly changing and developing. This meansthat nurses may add new functions to their work. When deciding to do so,nurses must be sure that patients will benefit and that they are competent forthe new role.

Nursing is a service which:

— Helps individuals, families and communities to achieve and maintaingood health.

— Supports, assists and cares for people during illness or when their healthis threatened.

— Enhances people's ability to cope with the effects of illness anddisability.

— Ensures, as far as possible, that death is dignified and free from pain.

Nursing achieves these goals by applying knowledge and skills gainedthrough education and training, updated and tested by research. It is thecombination of professional knowledge and skills, with the desire to care forothers, which provides the base of nursing.

Nursing practice includes:

— Assessing people's health, their health problems and the resources theyhave to cope with them, deciding what nursing help is needed andreferring them to other sources of expertise when necessary.

— Planning, giving and evaluating programmes of skilled nursing care.


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— Teaching individuals, families and communities about healthy lifestyles.This involves helping them gain the knowledge and skills to control theirown health.

— Teaching and enabling people to attain, maintain or recover theirindependence.

— Acting as the patient's advocate and communicating the patient's needsto others.

— Co-ordinating care where other health care workers are involved.

— Maintaining an environment conducive to health or recovery.

(Nursing Standard, vol. 6 no. 24, 1992, p. 35)

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