A Regulatory Framework for Nurse Practitioners in British Columbia
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1 2855 Arbutus Street Vancouver, BC V6J 3Y8 Tel A Regulatory Framework for Nurse Practitioners in British Columbia In December 2000, the Ministry of Health announced its decision to introduce nurse practitioners into the British Columbia health care system to improve public access to health care services in the province. The Ministry of Health and the College of Registered Nurses of British Columbia (CRNBC) partnered in this initiative. CRNBC began to register nurse practitioners in the fall of CRNBC was responsible for developing the competencies and the necessary processes to register registered nurses as nurse practitioners, including establishing of initial and renewal registration requirements and setting standards limits and conditions for the practice of nurse practitioners. The Ministry of Health was responsible for drafting regulations establishing the scope of nurse practitioner practice, addressing employment issues and funding educational programs. Ministry staff and CRNBC agreed on a set of eight principles that have been used to guide the implementation of nurse practitioners in the B.C. health care system. The eight principles are attached in Appendix A. Throughout the consultation process to develop the regulatory framework, stakeholders stressed that it is important for CRNBC to have rigorous regulation of nurse practitioners to assist in ensuring public safety and to demonstrate to the public and other stakeholders that the regulatory body appropriately and effectively regulates the practice of nurse practitioners. Stakeholders consistently told CRNBC that safe practice of nurse practitioners is better addressed through substantive regulatory requirements implemented by the nursing regulatory body than by having government set narrow limitations on nurse practitioner practice. This approach gives the regulatory body the clear responsibility to determine what practices are acceptable within broadly framed legislative authority. Rigorous regulation of nurse practitioners requires policy and processes in three separate but interdependent areas: competencies and approval of nurse practitioner education programs; initial registration requirements; and practice oversight, including registration renewal requirements. The approaches outlined in this document are set out in CRNBC Bylaws and policies. CRNBC Bylaws are subject to a three-month consultation period and the majority of the Bylaws require Cabinet approval before they can be implemented. 1 Until August 2005, CRNBC was formerly known as the Registered Nurses Association of British Columbia.
2 COMPETENCIES AND APPROVAL OF EDUCATIONAL PROGRAMS The first area required for regulation of nurse practitioners is the establishment of required competencies and the approval of nurse practitioner education programs based on these competencies. Core competencies required for nurse practitioners in B.C. and their application to the three categories in which CRNBC registers nurse practitioners family, adult, and pediatric were published in October The document outlining these competencies is available on CRNBC s website. Nurse practitioners in B.C. are registered nurses who have achieved the CRNBC competencies required for registration as a nurse practitioner. These competencies are usually achieved through graduate nursing education and substantial nursing practice experience. Nurse practitioners have the competence to provide health care services from a holistic nursing perspective combined with a focus on the diagnosis and treatment of acute and chronic illnesses, including prescribing medications. CRNBC has three broad, rather than highly specialized, client populations as the nurse practitioner categories in which nurse practitioners are registered. The nurse practitioner (family) provides health care services to persons across the life span, including newborns, children, adolescents, adults, pregnant and postpartum women and older adults. The nurse practitioner (adult) provides health care services to young, middle-aged and older adults. Care of older adolescents may also be provided by a nurse practitioner (adult) in some instances when the adolescent s development and/or lifestyle may be more similar to that of an adult. The nurse practitioner (pediatric) provides health care services to children from newborn infants to toddlers to school-aged children to adolescents. In some instances the nurse practitioner (pediatric) may provide care to young adults based on developmental age or where the young adult has been receiving care for a chronic illness since childhood (e.g., cystic fibrosis). Mental health, chronic illness and geriatrics at the primary care level are included in the competencies of the nurse practitioner (family) as these issues are important in primary care. The nurse practitioner (adult) and the nurse practitioner (pediatric) have more extensive knowledge about their respective population groups than the nurse practitioner (family). The nurse practitioner (adult), for example, has extensive theoretical and clinical education in the care of the chronically ill adult and the complex needs of the older adult. The nurse practitioner (adult) is prepared for practice in acute and long-term care as well as community settings. CRNBC uses the same approach with recognition of nurse practitioner educational programs as it takes with approval of basic nursing education programs. The process used for recognition of educational programs is set out in the CRNBC Bylaws and board policies. Programs recognized by CRNBC are listed on the CRNBC website. INITIAL REGISTRATION OF NURSE PRACTITIONERS The second area required for regulation of nurse practitioners by CRNBC is initial registration. There are three requirements for initial registration as a nurse practitioner in B.C.: 1. Current practising registration as a registered nurse in B.C. or eligibility for registration as a registered nurse in B.C. 2. Graduation from a CRNBC-recognized nurse practitioner program or equivalent. A prior learning assessment and recognition (PLAR) process is available for applicants who are not graduates of B.C. approved programs. This process is still under development for those without master s level education. 3. Successful completion of both a written and a clinical examination. In prior learning assessment and recognition, the individual s prior learning (both formal and informal) is evaluated against established standards, such as course learning outcomes or professional standards and competencies so that an academic institution or professional regulatory body may grant recognition. The assessment is carried out by qualified 2 COLLEGE OF REGISTERED NURSES OF BRITISH COLUMBIA
3 experts using valid and reliable means. There are currently significant differences in educational preparation and scope of practice for nurse practitioners across Canada. Therefore, CRNBC is developing rigorous PLAR processes to establish equivalency of all applicants other than B.C. graduates (i.e., not just for international applicants as is the case for registered nurses). The process for assessing applicants prepared at the master s level is available. It comprises an indepth assessment of academic preparation, including assessment of transcripts, nurse practitioner program content and content of other relevant education as appropriate. A more detailed PLAR process will be available in 2008 for those who have not been prepared at the master s level. It is expected that it will include a portfolio assessment, a face-toface panel assessment and a clinical assessment in the practice setting. Additional details on the PLAR process can be found on CRNBC s website. All nurse practitioner applicants for registration with CRNBC are required to successfully complete two registration examinations a written examination and an objective structured clinical examination (OSCE). Based on an assessment of available examinations, CRNBC selected the American Nurses Credentialing Center (ANCC) online examinations (family, adult, pediatric) as the most appropriate at this time. CRNBC developed an OSCE for each category of practice (family, adult, pediatric). The OSCE is a structured performance test comprising a series of separate testing stations using simulated or standardized patient scenarios performed by trained actors who provide real-life interactions with the candidate. The candidate s performance is tested using structured marking sheets of directly observed performance to provide a high level of validity and reliability. Psychometric testing is carried out on the clinical examination. The OSCE is designed to test broad competencies such as history taking, physical examination, ability to perform procedures, clinical reasoning, patient education and communication skills. From a regulatory perspective, it is one of the few assessment tools that has been shown to be valid and reliable in assessing a candidate s application of clinical competencies. Other professions, such as medicine, pharmacy, and physiotherapy, require an OSCE as part of initial registration. Although approval of nurse practitioner education programs is seen as a key component to ensure that applicants have the appropriate competencies, examinations, both written and OSCE, were identified as a necessary part of verifying competencies of the individual applicant. The educational program approval process is focused on aggregate information spanning up to five years, the maximum length of program approval. It does not examine in-depth or directly the achievement of individual graduates. OVERSIGHT OF NURSE PRACTITIONER PRACTICE The third area required for regulation by CRNBC is practice oversight. This includes setting standards and requirements for registration renewal (i.e., continuing competence and quality assurance). CRNBC s Nurse Practitioner Standards Committee recommends standards, limits and conditions for nurse practitioner practice to the CRNBC Board. The responsibilities of this Committee are set out in the Nurses (Registered) and Nurse Practitioner Regulation and the CRNBC Bylaws. The committee consists of two physicians and a pharmacist who have worked with nurse practitioners, a government representative, a public representative from the CRNBC Board and seven registered nurses or nurse practitioners (including a representative from the schools of nursing preparing nurse practitioners). The committee supports transparency and openness to the perspectives of others while maintaining the principle of self-regulation. Nurse practitioners are required to meet standards, limits and 2 The scope of practice documents for all three streams are: Scope of Practice for Nurse Practitioners (Family): Standards, Limits and Conditions; Scope of Practice for Nurse Practitioners (Adult): Standards, Limits and Conditions; and Scope of Practice for Nurse Practitioners (Pediatric): Standards, Limits and Conditions. COLLEGE OF REGISTERED NURSES OF BRITISH COLUMBIA 3
4 conditions as one part of the requirements for initial and ongoing registration as a nurse practitioner. 2 The standards, limits and conditions, together with the Competencies Required for Nurse Practitioners in British Columbia are used in the approval process for nurse practitioner education programs in B.C. The nurse practitioner is the newest category of registered nurse practice in B.C. Nurse practitioners have a legislated scope of practice beyond that of registered nurses, thus requiring additional regulation by CRNBC. The Health Professions Act provides for regulatory colleges to impose continuing competence requirements, and pending amendments to the Health Professions Act, will require all colleges to establish additional quality assurance programs. Specific requirements for continuing competence are available on the CRNBC website. As registered nurses, nurse practitioners comply with the CRNBC Continuing Competence Program Requirements for registered nurses. There are additional continuing competence requirements for nurse practitioners related to nurse practitioner standards and competencies for practice. To determine compliance with the Continuing Competence Program Requirements, nurse practitioners are required to annually submit information related to the additional nurse practitioner requirements. In addition, the CRNBC Board has approved requirements for a quality assurance on-site peer practice review. The intent is to review nurse practitioner practice and provide support and, where necessary, direction for the individual in meeting the nurse practitioner standards and maintaining the competencies for nurse practitioner practice. The quality assurance practice review is also intended to identify systemrelated issues that CRNBC and others would need to address to enable safe nurse practitioner practice. The quality assurance practice review occurs within the first two years of practice for each new nurse practitioner registrant in B.C. and subsequently will occur through a combination of random and targeted quality assurance practice reviews at least once every five years. 3 As part of the Quality Assurance Program, CRNBC is planning to review nurse practitioner prescribing patterns using PharmaNet data. This additional review process will require legislative change by government. Having the capability to monitor prescribing patterns of nurse practitioners is an important regulatory tool in the oversight of nurse practitioner practice. Issues related to complaints about an individual nurse practitioner s practice have been addressed in the bylaws on inquiry and discipline under the Health Professions Act. CRNBC already has systems and processes in place to handle complaints about registered nurse practice and these systems have been expanded to address complaints about nurse practitioner practice. Another regulatory tool, introduced by government under the Health Professions Act, is mandatory reporting. All health professionals are required to report another health professional to that person s regulatory college if they have reasonable and probable grounds to believe that person s practice might constitute a danger to the public. CONCLUSION The key principle underlying decisions regarding the implementation of the nurse practitioner role in B.C. is that decisions are made in the public interest. It is essential that nurse practitioners be able to practise with autonomy and flexibility in order to safely meet the needs of the public. CRNBC is confident that this rigorous regulatory framework provides the tools for the College to appropriately and effectively regulate the practice of nurse practitioners. Copyright College of Registered Nurses of British Columbia/June 07 07W14 3 The frequency will be reviewed five years after the introduction of nurse practitioners in B.C. 4 COLLEGE OF REGISTERED NURSES OF BRITISH COLUMBIA
5 APPENDIX A: PRINCIPLES GUIDING THE NURSE PRACTITIONER PROJECT 1. The best interests of the public will be the key priority driving decisions on the implementation of the nurse practitioner role. This principle is consistent with the public first guideline that was put forward by the 1991 Royal Commission on Health Care report Closer to Home. This principle states that public servants and professional colleges must always put the public interest ahead of their own or their members interest. This principle is consistent with the statutory duty of CRNBC to serve and protect the public and to exercise its authority in the public interest. 2. The implementation of nurse practitioners will be consistent with the principles of B.C. s public health system. Appropriate use of the skills and knowledge of nurse practitioners will support a sustainable health system that is cost-effective, accessible, comprehensive, and of high quality. The formalization of nurse practitioners must be carried out in ways that help keep our publicly funded health system sustainable. 3. The need for improved health care access and effective utilization of health care providers will guide implementation of the nurse practitioner role. The roles of all health professionals should be guided by an assessment of who is the most appropriate provider to deliver the service. This requires a degree of flexibility in how services are provided. Nurse practitioners have a role to play in maximizing the quality and accessibility of appropriate care. 4. The provision of nurse practitioner care will occur in all health care settings where there is a health system need. Nurse practitioners will practise in a broad variety of settings where there is a health system need. This includes acute care, residential care, mental health and community practice. Nurse practitioners provide essential health care across the continuum of health care services, including health promotion, disease and injury prevention, curative care, supportive care and rehabilitative care. 5. Legislation governing the regulation of nurse practitioners will be based on and comparable to legislation guiding other health professions. As for all registered nurses, the governance of nurse practitioners will parallel the governance of other health professions. In B.C., all health professions have a scope of practice that is set out in legislation and regulations. This is necessary to indicate to the public and to the other members of the interdisciplinary team what services the health professional is authorized to perform. 6. The regulation of nurse practitioners will be flexible to accommodate all practice environments of nurse practitioners. In some jurisdictions where nurse practitioners are regulated, their role was initially defined so narrowly that the legislation quickly became out-dated. By building flexibility into the legislative model for nurse practitioner regulation in B.C., the reality of different practice environments can be accommodated. 7. Regulation of nurse practitioners in B.C. will be the responsibility of CRNBC, the established regulatory body for registered nurses. It makes sense for the existing regulatory body for registered nurses to regulate nurse practitioners. CRNBC will develop a profile of practice that will outline the competencies that a registered nurse must achieve in order to be qualified as a nurse practitioner. In addition, CRNBC will establish the standards of practice and any limitations on the practice of nurse practitioners. 8. The regulation of nurse practitioners will be competencebased. CRNBC will outline the competencies that are required of nurse practitioners. These will be used in the development of educational programs for registered nurses who wish to become nurse practitioners. In addition, a process for challenging the required competencies will be developed for registered nurses who have already achieved them through a combination of education and experience rather than through graduation from a formal nurse practitioner education program. The required competencies will be also be used to assess the skills of registered nurses from other jurisdictions who may wish to qualify as nurse practitioners in B.C. Adapted from the Ministry of Health s Consultation Paper: Nurse Practitioner Project (February 2002) COLLEGE OF REGISTERED NURSES OF BRITISH COLUMBIA 5
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