RECOMMENDATIONS OF THE CANADIAN NURSE PRACTITIONER INITIATIVE PROGRESS REPORT

Transcription

1 RECOMMENDATIONS OF THE CANADIAN NURSE PRACTITIONER INITIATIVE PROGRESS REPORT December 2009

2 This report has been prepared by CNA to provide information on a particular topic or topics. The views and opinions expressed in this report do not necessarily reflect the views of the CNA board of directors. Funding for this publication was provided by Health Canada. The opinions expressed in this publication are those of the authors and do not necessarily reflect the official views of Health Canada. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, or transcribed, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission of the publisher. Canadian Nurses Association 50 Driveway Ottawa, ON K2P 1E2 Tel.: or Fax: Website: December 2009 ISBN Photos: Greg Teckles Photography Inc.

3 TABLE OF CONTENTS Executive Summary 3 Introduction 4 Methods 5 Findings 7 Response Rates 7 Project Data: Responses Concerning the 84 Actions 8 Strategic Area: Legislation and Regulation 8 Strategic Area: Practice 15 Strategic Area: Health Human Resource Planning 16 Strategic Area: Education 19 Strategic Area: Strategic Communications, Change Management and Social Marketing 24 Strategic Area: Evaluation 26 Strategic Area: Governance 26 Project Data: Broad Questions 27 Discussion 29 Summary of Findings 29 Outstanding Key Issues 31 Legislation and Regulation 31 Practice 31 Health Human Resource Planning 32 Education 32 Change Management 32 Social Marketing and Strategic Communication 33 The Need for an Updated Plan of Action 33 Stakeholders 34 Provincial/Territorial Jurisdictions 34 Principal Nursing Advisers and Other Nursing Representatives from the Federal/Provincial/Territorial Governments 34 Nurse Practitioner (NP) Associations (Provincial and Territorial) or Nurse Practitioner Contacts 36 Representatives of Nurse Education Programs for NPs in Canada 37 Other Stakeholders 39 References 40 CANADIAN NURSES ASSOCIATION 1

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5 EXECUTIVE SUMMARY In the first three months of 2009, the Canadian Nurses Association (CNA) consulted with stakeholders and analyzed the progress made on meeting the recommendations generated from the 2006 Canadian Nurse Practitioner Initiative (CNPI). Questionnaires were developed on the basis of the action plan the CNPI proposed in its report The Way Forward Plan: Committing to Action (CNA, 2006h). Results indicate that more than half of the actions have been fully or partially completed since 2006, and that several key actions remain in progress or are not completed. 1 Details of these results are presented in this report. This report is limited in that some jurisdictions were over-represented during the consultation process, whereas others did not have adequate representation from all stakeholder groups. Information from the consultations suggests, however, that many of the issues now faced in relation to the continued implementation of the nurse practitioner role require collaboration across jurisdictions and sectors if they are to be successfully resolved. In The Way Forward Plan, the CNPI proposes the development of a multi-stakeholder, multi-jurisdictional coordinating committee. Supporters and participants were concerned that key stakeholders would act independently rather than implement the CNPI s recommendations from a pan-canadian perspective, and that it would not be possible to achieve systemic change if a traditional jurisdictional implementation approach was followed. Health Canada s Office of Nursing Policy has taken the first step toward achieving systemic change by asking CNA to carry out this review of the status of the CNPI s recommendations. Many outstanding key issues described in this report will need further discussion. It is recommended that the Office of Nursing Policy consider convening a multi-stakeholder, multi-jurisdictional forum to review the current CNPI list of recommendations and actions and develop an updated action plan with clear, achievable goals. 1 Four status levels concerning the recommended key actions are used in this report: (1) completed, all activities completed; (2) partially completed, activities have been implemented to some extent; (3) action ongoing, activities in the process of being conducted; and (4) not completed, no actions reported. CANADIAN NURSES ASSOCIATION 3

6 INTRODUCTION As part of its commitment to provide better access to primary health services to all Canadians, the government of Canada created the Primary Health Care Transition Fund (PHCTF) (CNA, 2006g) in The fund provided $8.9 million in financial support to the Canadian Nurse Practitioner Initiative (CNPI), which had an 18-month mandate to develop a pan-canadian framework to support the sustained integration of the nurse practitioner (NP) role into Canada s health-care system. NPs play an important role in health care: they are registered nurses with additional educational preparation and experience who possess and demonstrate the competencies required to autonomously diagnose, order and interpret diagnostic tests, prescribe pharmaceuticals and perform specific procedures within their legislated scope of practice (CNA, 2006d, p. 19). In June 2006, the CNPI published Nurse Practitioners: The Time is Now, a report containing 13 recommendations to integrate NPs into the Canadian health-care system. The CNPI then produced The Way Forward Plan: Committing to Action (CNA, 2006h) to map out the next steps required to implement the recommendations so that the CNPI vision for the NP role could become a reality. A detailed plan can be found in Appendix B, Nurse Practitioner National Implementation Plan: Suggested Roll-out (CNA, 2006a). This plan includes 84 actions for the 13 CNPI recommendations, grouped into the following seven strategic areas: legislation and regulation; practice; health human resource planning; education; strategic communications, change management and social marketing; evaluation; and governance. For each of the 84 actions, the implementation plan identifies a priority, timeline, lead or co-lead and key supporting stakeholder groups. CNA was the sponsoring organization for the CNPI and continues to promote the implementation of the NP role in Canada. The provinces and territories have worked with the CNPI recommendations and while some progress is apparent, there has been no national coordinated effort nor information compiled recording any success in implementing the recommendations from a pan-canadian perspective. There was some concern, however, among supporters and participants of the CNPI that the resulting recommendations would not be implemented across Canada (CNA, 2006h). The Canadian Nurses Association (CNA) s vision is as follows: Registered nurses: leaders and partners working to advance health for all. One of CNA s strategic goals in pursuit of this vision is to promote awareness of the nursing profession so that the roles and expertise of registered nurses are understood, respected and optimized within the health-care system. From January to March 2009, CNA led a project to document the status of the 13 CNPI recommendations with the aim of providing current data for decision-makers and stakeholders such as federal/provincial/territorial (F/P/T) governments, provincial/ territorial (P/T) nursing regulatory colleges and associations, nursing professional groups and nursing educational associations. CNA consulted with representatives from governments and nursing organizations, regulators, educators and NPs across Canada. The results of this project are presented in this report. The current status of each of the actions identified by the CNPI is presented and key outstanding issues are identified from the report. Decision-makers and stakeholders will be able to use these data to redefine priorities for the support of the NP role in the Canadian health-care system. 4 RECOMMENDATIONS OF THE CANADIAN NURSE PRACTITIONER INITIATIVE: PROGRESS REPORT

7 METHODS The Nurse Practitioner National Implementation Plan: Suggested Roll-out was used by CNA as the basis for the questions used in the consultations (CNA, 2006a). To ascertain the current status, questions were developed relating to each of the 84 action items. The status of each of the following eight actions, identified by strategic area and key action number, was not investigated because they were deemed to be too broad for this project. Develop and implement a framework to facilitate the practice of extended/expanded role of registered nurses. (Legislation and regulation, 19) Reflect the guiding philosophy, assumptions and values found in the Education Framework for Nurse Practitioners in Canada. (Education, 38) Develop philosophy, mission and goal statements that are aligned with pan-canadian frameworks governing NP education and periodically assess and review them. (Education, 43) Be responsive to broadly defined, evidence-based stakeholder needs. (Education, 46) Develop preceptor preparation programs. (Education, 57) Implement evidence-based student evaluation and testing methodologies. (Education, 62) Establish a pan-canadian resource bank, including approaches and tools. (Education, 63) Implement cross-jurisdictional collaboration among schools and regulatory bodies to ensure that the licensure-to-practice process for NP students is supported by NP educational program content and teaching and learning processes. (Education, 64) CNA identified the stakeholders (leads, co-leads or key supporting stakeholder groups) for each of the actions, then prepared an individualized questionnaire relating to the actions for each group as identified in the implementation plan. A number of actions were designated to be undertaken by more than one stakeholder group, and thus there was some overlap among the questionnaires. Questionnaires were tailored for representatives of each of the following stakeholder groups: principal nursing advisers and other nursing representatives from F/P/T governments in Canada; educational programs for NPs in Canada; Canadian Association of Schools of Nursing (CASN); nursing regulatory bodies and CNA jurisdictional members representing each province and territory; Canadian Health Services Research Foundation/Canadian Institute of Health Research (CHSRF/ CIHR) Chair Program in Advanced Practice Nursing; Canadian Nurses Protective Society (CNPS); Canadian Federation of Nurses Unions (CFNU); CNA; CANADIAN NURSES ASSOCIATION 5

8 Health Canada s Office of Nursing Policy; the Canadian Association of Advanced Practice Nurses (CAAPN), provincial NP associations and interest groups; and NPs across Canada. Five questionnaires were developed using the SurveyMonkey software. The questionnaires were piloted with NPs and representatives from CASN, CNA and others. The questionnaires were translated, except for the ones prepared for unilingual respondents. Data collection with all stakeholders occurred between January 26 and February 20, 2009, and in June The majority of data were collected through an electronic survey program. Some of the data were collected by or during semi-structured interviews as a number of questionnaires had fewer than five stakeholders. Additional data from an unpublished discussion document on the regulation of NPs in Canada, Regulation of Nurse Practitioners in Canada: A Discussion Document, were used to document findings related to the CNPI s strategic area of legislation and regulation. Additional summary questions were asked of five groups of respondents: (1) principal nursing advisers and other nursing representatives from F/P/T governments in Canada; (2) representatives of nursing regulatory bodies and CNA jurisdictional members; (3) representatives of the Canadian Association of Advanced Practice Nurses, provincial NP associations and interest groups; (4) NPs; and (5) representatives of educational programs for NPs in Canada. The questions were meant to identify changes that had occurred since 2006 on meeting the CNPI s recommendations and to identify the current priorities of these respondents. Customized to each group, the questions were to encourage respondents to answer from the perspective of their own organization and role. They were: Since the CNPI project made its recommendations in 2006, what have been the major changes? What do you see as the key priorities? In addition, NPs were asked: What supports are important in establishing your NP practice? Describe any barriers that you are experiencing in your current role as an NP. Employers of NPs were identified in the implementation plan as the leads or co-leads for a number of actions, and were not consulted for the present project because of time constraints. Instead, NPs were asked questions concerning their employer, where appropriate. The Mutual Recognition Agreement (MRA) working group was formed early in 2006 by the P/T regulatory bodies and CNA to plan and facilitate the development of a new MRA for RN and NP regulation in Canada. The second phase of the project began in The P/T regulatory bodies met to facilitate the movement of NPs from one jurisdiction to another within Canada. The MRA working group gave CNA permission to use the data that were collected as part of the MRA discussions in the development of this report. Where possible, these data were used so that CNA could avoid collecting duplicate data from regulators. Except for information that is publicly available, data in this report were validated by stakeholders. 6 RECOMMENDATIONS OF THE CANADIAN NURSE PRACTITIONER INITIATIVE: PROGRESS REPORT

9 FINDINGS Response Rates All 12 P/T principal nursing advisers were sent a questionnaire, as were the following federal agencies: First Nations and Inuit Health Branch and Office of Nursing Policy at Health Canada, Veterans Affairs Canada, Department of National Defence and Correctional Service of Canada. Nineteen responses were received from this group, including responses from all of the P/T principal nursing advisers, except Quebec. This sample provides a pan-canadian perspective of P/T opinions from governments and federal agencies. A questionnaire was sent to all nursing regulatory bodies and CNA jurisdictional members. The regulatory bodies in all of the provinces and territories responded, except Quebec, resulting in a total of 11 responses. A questionnaire was sent to CAAPN and to NP associations and interest groups in nine of the provinces (Prince Edward Island does not have an association or interest group of NPs). Some associations and interest groups provided multiple responses, some associations provided a single response and some did not respond, so the sample does not provide a pan-canadian perspective. A total of 23 responses were received in this category. NP associations were asked to send the NP questionnaire to NPs in their province. In areas where there is no formal NP interest group (territories and Prince Edward Island), key contacts in these jurisdictions were asked to forward the questionnaire to NPs in their territory or province. Yukon has recently enacted legislation to implement the NP role; however Yukon was not represented in this sample. According to a 2009 report from nursing regulatory bodies, there are approximately 2,000 NPs in Canada; 44 responses were received, for a response rate of approximately 2%. The number of responses was insufficient to permit analysis of the data by jurisdiction, but the responses provide common areas and some differences between the provinces and territories. A questionnaire was sent to all directors of educational programs for NPs. The list of programs used in this project was validated by CASN. Responses were received from at least one educational program for NPs in almost every province. (There are currently no educational programs for NPs offered in Prince Edward Island, Nunavut and Yukon.) Responses were received from 15 of the 28 schools, for a response rate of 54%. One jurisdiction is not represented in the findings. Responses were also received from the CHSRF/CIHR Chair Program in Advanced Practice Nursing, CNPS, CASN, CFNU, and CNA. The people consulted from CNA were not involved in the data collection processes. 2 2 This is to minimize bias in the data collection process as CNA was the project leader. CANADIAN NURSES ASSOCIATION 7

10 Project Data: Responses Concerning the 84 Actions Summarized below are the respondent s views related to each of the 84 actions as set out in the implementation plan. The data are grouped under the 13 CNPI recommendations, which are in turn organized according to the strategic areas established by the CNPI: legislation and regulation; practice; health human resource planning; education; strategic communications, change management and social marketing; evaluation; and governance. STRATEGIC AREA: Legislation and Regulation RECOMMENDATION 1 Adopt the Legislative and Regulatory Framework. Key Actions Status Report Role Clarity 1. Enact and implement a broad scope of practice for nurse practitioners based Partially on pan-canadian core competencies. completed 2. Adopt the recommended NP definition. Completed 3. Protect the Nurse Practitioner title and designation in legislation in all Completed Canadian jurisdictions. 4. Adopt a mandatory requirement for a minimum of $5 million of professional Partially liability protection for nurse practitioners in Canada. completed 5. Expand the national registered nurses database (Canadian Institute of Completed Health Information) to include relevant information on nurse practitioners. 6. Include public membership/participation on all nursing regulatory Completed boards/councils and their statutory committees. 7. Provide information about the role of the nurse practitioner to consumers. Action ongoing Initial and Continued Competency 8. Adopt the Canadian Nurse Practitioner: Core Competency Framework (2005). Completed 9. Adopt standardized requirements for registration/licensure of nurse practitioners. Not completed; see also Action Adopt the Canadian Nurse Practitioner Examination (CNPE). Partially completed 8 RECOMMENDATIONS OF THE CANADIAN NURSE PRACTITIONER INITIATIVE: PROGRESS REPORT

11 11. Adopt the Competence Assessment Framework for Nurse Practitioners in Canada. Include successful completion of the CNPE and a clinical practice assessment as requirements for registration/licensure of NPs initial practice. Partially completed Adopt a combination of approaches, including an annual self-assessment, peer review, the development and evaluation of a professional development plan, and a structured clinical assessment every 3 5 years as the minimum requirements for nurse practitioner continuing competence assessment. Adopt the Prior Learning Assessment and Recognition Framework (PLAR) to support the assessment of nurse practitioner applicants whose credentials and/or education cannot be accurately assessed or are judged to be inadequate. Employment Mobility 12. Develop and implement a mutual recognition agreement for nurse practitioners. Not completed 13. Reduce unnecessary barriers to Canadian and internationally educated nurse Partially practitioners applying for registration/licensure. completed Regulatory Effectiveness 14. Adopt the 10 underlying principles 3 as the basis for nurse practitioner legislative Completed and regulatory processes. 15. Amend existing F/P/T statutes to be consistent with nurse practitioner practice. Partially completed 16. Apply the professional conduct mechanisms and processes of RN legislation Completed and regulation to nurse practitioners. 17. Engage the public and other stakeholders in the development of legislative and Completed regulatory processes for nurse practitioners. 18. Develop and adopt a pan-canadian evaluation framework to assess the Not effectiveness of nurse practitioner regulatory mechanisms and processes. completed Extended/Expanded RN Role 19. Develop and implement a framework to facilitate the practice of extended/ Status not expanded role registered nurses. investigated 20. Establish consensus on standardized mechanisms to support the practice of Not registered nurses in the extended/expanded role. completed 3 These 10 principles can be found in Legislative and Regulatory Framework (CNA, 2006c). CANADIAN NURSES ASSOCIATION 9

12 This strategic area included actions 1 to 20 from the implementation plan, and the questionnaires sent to representatives of regulatory bodies and CNA jurisdictional members included questions on these 20 actions. Other groups (i.e., CNA, CNPS, principal nursing advisers and other nursing representatives from F/P/T governments, CAAPN, NP associations) were identified as stakeholders for some of these actions related to legislation and regulation in the implementation plan and, thus, their questionnaires included questions concerning the relevant actions. Eight of the 20 actions have been completed, six have been partially completed, one was classified as ongoing, four have not been completed and one was not included in the questionnaires. The CNPI technical report Legislative and Regulatory Framework (CNA, 2006d) promotes a consistent approach to the legislation and regulation of NPs in all Canadian jurisdictions. The following is a summary of the findings for each of the 20 actions in the legislation and regulation strategic area. Role Clarity All respondents agreed that a broad scope of practice for NPs based on pan-canadian core competencies should be enacted and implemented. One jurisdiction has further elaborated the core competencies and specified how the competencies are applied in practice within the three NP registration categories: NP family/all ages, NP (adult) and NP (pediatric). Implementation of broad core competencies has been partially completed: half of the respondents reported that this action has not been achieved within their jurisdictions. Some respondents commented that legislative changes were currently underway in their jurisdictions. Implementation of the NP scope of practice hinges on governmental support for putting in place legislative changes to enable a broad scope of practice. The respondents indicated that further work is needed before NPs can be given a broad scope of practice within the prescribing authority. There are restrictions that limit the ability to prescribe controlled substances and to initiate prescribing in in-patient tertiary care settings. Allowing NPs to prescribe controlled substances and changing some of the jurisdictional legislation would enable NPs to practise within their scope of practice in in-patient tertiary care settings. The CNPI s definition of nurse practitioner is integrated into the policy documents of CNA and its jurisdictional associations. Respondents from some representatives of regulatory bodies and CNA jurisdictional members noted that elements of the definition have been used in publications produced by their own organization, standards of practice and framework documents. The title Nurse Practitioner is now protected in all Canadian jurisdictions in which NP legislation exists. Most NP registrants have liability protection of $5 million, as recommended by the CNPI, through their registration as an NP. However, this is not the case in Ontario and Quebec. Liability coverage in Quebec is offered through a private insurer. In Ontario, NPs obtain liability coverage with CNPS through the Registered Nurses Association of Ontario or their employer. The Canadian Institute for Health Information (CIHI) collects data on NPs, although respondents made suggestions to improve and expand these data, such as adding an NP registration category. The NP registration category is different in some jurisdictions and includes specialty streams. Other suggestions were to add questions on workload benchmarks for NPs, and to add a report on NPs whose registration has lapsed and who would like to practise again. 10 RECOMMENDATIONS OF THE CANADIAN NURSE PRACTITIONER INITIATIVE: PROGRESS REPORT

13 The public is involved in NP legislation and regulation through membership on regulatory boards and councils in all jurisdictions. Respondents from six representatives of regulatory bodies and CNA jurisdictional members reported that they provide information about the NP role to consumers. The CNA website includes a number of documents related to NPs, such as fact sheets, position statements and CNPI documents, and several organizations are working to develop information targeted to the public. CNA reported research results indicating that the public s awareness of NPs has not changed significantly since 2006 (Decima, 2006 & Ekos, 2008). Initial and Continued Competency The CNPI s Canadian Nurse Practitioner: Core Competency Framework (CNA, 2005b) has been adopted by the majority of regulators. A respondent from one regulatory body questioned whether the framework can stand alone as the standard for the educational preparation of NPs and the assessment of applicants for registration. There is agreement in principle among regulators that standardized requirements for registration/licensure should be adopted, but this will require significant work. Consistency of educational preparation, scope of practice, assessment processes and streams or registration categories of NPs has not yet been achieved. Some of the actions in this section refer to another CNPI technical report: Competence Assessment Framework for Nurse Practitioners in Canada (CNA, 2006b). The recommendations from this framework have been only partially met. There is variation in the initial assessment processes for NPs, including prior learning assessment and recognition (PLAR) processes and the types and kinds of examinations. Most jurisdictions have a continuing competence program, but only two require a clinical assessment every three to five years. A number of jurisdictions are in the process of planning such a requirement. There was general agreement among the respondents that an examination is required to practise as an NP, but some respondents from two jurisdictions questioned whether the current Canadian Nurse Practitioner Examination: Family/All Ages (CNPE: F/AA) is adequate, or whether a clinical examination should also be required. Progress has been made in reaching some consensus on the streams or registration categories of NPs, although there are still some differences across the country (see Table 1). Written examinations are now available for three categories: NP family/all ages, NP (adult) and NP (pediatric). The CNPE: F/AA is used in 8 of 10 provinces. (The territories register NPs after they have been registered elsewhere in Canada.) One jurisdiction uses the American Nurses Credentialing Center (ANCC) Family exam, while five jurisdictions use the ANCC adult and pediatric NP exams (J. Barry, personal communication, 2009), and another jurisdiction has developed its own exams for its registration categories. Two jurisdictions require all NP applicants to successfully complete the Objective Structured Clinical Examination (OSCE) for their registration categories. A pan-canadian assessment centre has not yet been established. Respondents from six representatives of regulatory bodies and CNA jurisdictional members supported this initiative; they believed that such a centre would be helpful for international applicants and for the development of common standards for assessment in Canada under the Agreement on Internal Trade. CANADIAN NURSES ASSOCIATION 11

14 Table 1: Nurse Practitioner Examinations Currently Available in Canada Jurisdiction CNPE: Adult Pediatric Family Other Family/All Ages (ANCC) (ANCC) (ANCC) British Columbia Alberta Saskatchewan Manitoba Ontario Quebec New Brunswick Nova Scotia Prince Edward Island Newfoundland and Labrador Northwest Territories Nunavut NA Yukon NA NA NA NA Note: ANCC = American Nurses Credentialing Center; NA = not applicable. Employment Mobility All provinces and territories recently agreed to an amendment to Chapter 7 of the Agreement on Internal Trade. The amendment no longer requires mutual recognition agreements (MRA), referred to in Action 12 of the CNPI, but does require all provinces and territories to remove any barriers to mobility. Mutual recognition is considered to occur when qualified workers from other jurisdictions are recognized without any additional retraining, retesting or reassessment. No additional requirements are imposed on the worker and there is no need for individual case-by-case assessment. Any exceptions are to be clearly identified and justified as required to meet legitimate objectives determined by the governments (e.g., for the protection of health or public safety). After April 1, 2009, governments were required to indicate that mutual recognition exists unless a legitimate objective for maintaining additional requirements is approved or the category of worker does not exist in the jurisdiction. Regulators are working together to try to achieve consistency, but government action is also necessary, for example, to change legislated requirements that represent a barrier to mobility. The scope of practice for NPs continues to vary across the country (e.g., some jurisdictions do not permit NPs to diagnose chronic disease, or require them to work in a collaborative practice). Regulators who responded to the present survey raised concerns that even if educational preparations, scope of practice and registration processes are harmonized, historical differences remain. For example, NPs who 12 RECOMMENDATIONS OF THE CANADIAN NURSE PRACTITIONER INITIATIVE: PROGRESS REPORT

15 were assessed and registered before the harmonization had to meet different registration requirements, with some jurisdictions not requiring an examination, or where the scope of practice was expanded and additional regulatory oversight was not implemented. Regulatory Effectiveness The CNPI legislative and regulatory framework recommends 10 principles for NP legislative and regulatory processes. The respondents from P/T regulatory bodies agreed with the 10 principles but noted that their implementation required support from government. For example, Principle 6 states, The framework promotes sufficient rigor to ensure safe practice by autonomous nurse practitioners with a broad scope of practice (CNA, 2006c, p. 19). Some of the respondents reported regulatory changes that support a broad scope of practice in their jurisdiction. Others reported that further changes in legislation and regulation are needed to achieve this goal. One regulatory body raised the same issue of concern for public safety when the scope is expanded and a commensurate increase in regulatory oversight is not implemented. There has been little change in most jurisdictions regarding the inclusion of NPs in legislation for hospitals, workers compensation and motor vehicles. The federal government has not yet implemented the regulation that allows NPs to prescribe controlled substances. There are also barriers to NP practice within federal policies, such as the unemployment insurance and disability forms. Examples of federal legislation that omits nurse practitioners include: Narcotic Control Regulations under the Controlled Drugs and Substances Act; Canada Pension Plan Disability policies to complete the medical report section of the benefits application form; Employment Insurance disability benefits medical report section of the benefits application form; and Food and Drugs Act regulations that do not allow NPs to distribute drug samples to their clients. These federal laws have created significant barriers to nursing practice. NPs are not able to provide full range of care to their clients. The majority of respondents from F/P/T governments reported changes related to the Registered Nurses Act and the Pharmacy Act that directly relate to NP prescribing authority. Others are concerned with the inability of NPs to prescribed narcotics. All regulators apply professional conduct mechanisms and processes of registered nurse legislation and regulation to NPs. In addition, there is consensus on the engagement of the public and other stakeholders in the development of legislative and regulatory processes for NPs. The development of a pan-canadian evaluation framework to assess the effectiveness of NP regulatory mechanisms and processes has not been completed, but there is ongoing dialogue on this issue. CANADIAN NURSES ASSOCIATION 13

16 Extended/Expanded RN Role During the CNPI s consultations, a number of concerns were raised about the work of RNs who were practising in expanded roles that included skills common to the nurse practitioner role but did not meet the requirements for registration as an NP (CNA, 2005a). This concern was mainly related to RN practice in northern and remote communities where this role is evolving. In fact, one jurisdiction offers NP services for on-call support for RNs in these practice areas. It was recommended that standardized mechanisms to support such practice be developed. This has not occurred; however, many jurisdictions continue to authorize these activities through some form of delegation from physicians. Two jurisdictions include this expanded role in the scope of practice for RNs. One indicated that their jurisdiction s Health Professions Act enables the regulatory body to register an RN in a separate class of practice called certified practice. RNs in this class must have successfully completed a certified practice course and exit evaluation approved by the regulatory body and must apply to the regulatory body for certified practice designation. Rural remote practice is one of the designations. The results of this project indicate that the following five actions from the legislation and regulation strategic area have not been completed: 1. Identify barriers to employment mobility and look for ways to remove these barriers or to apply for exemptions under legitimate objectives. Develop and implement an MRA for NPs. 2. Adopt standardized requirements for registration/licensure of NPs. 3. Amend existing F/P/T statutes to be consistent with NP practice. 4. Develop and adopt a pan-canadian evaluation framework to assess the effectiveness of NP regulatory mechanisms and processes. 5. Establish consensus on standardized mechanisms to support the practice of RNs in the extended/expanded role. 14 RECOMMENDATIONS OF THE CANADIAN NURSE PRACTITIONER INITIATIVE: PROGRESS REPORT

17 STRATEGIC AREA: Practice RECOMMENDATION 2 Adopt the Practice Framework for Nurse Practitioners in Canada in order to facilitate consistency in F/P/T approaches to practice. Key Actions Status Report Role Clarity 21. Adopt the CNPI NP role description. Partially completed Interprofessional Collaborative Practice 22. Develop and implement clear policy direction for models of interprofessional Partially primary health-care (PHC) service delivery and a supportive change completed management strategy. Liability for All Health-Care Professionals Including Nurse Practitioners 23. Ensure all health professionals have liability insurance protection. Partially Explore interprofessional team liability coverage. completed 24. P/T governments cover the costs of professional practice and liability protection Partially as is done for other professionals in the province. completed 25. Establish a national voluntary database to track claims and payments made Not against health providers, including NPs. completed This strategic area included actions 21 to 25 from the implementation plan. A questionnaire was sent to all nursing regulatory bodies, CNA, CNPS, all principal nursing advisers and nursing representatives of the F/P/T governments, CAAPN, and NP associations. Four actions were partially completed and one action was not completed. In its final report (CNA, 2006g), the CNPI concluded that Practice Framework for Nurse Practitioners in Canada supports the diversity and complexity of the NP role within the health-care system. Regulatory bodies, CNA and employers are using CNPI s role description for NPs, although some have made minor or significant changes to it. CNA included the CNPI s NP role description in the revised edition of its document Advanced Nursing Practice: A National Framework (CNA, 2008). Action 22 the development and implementation of a clear policy direction for models of interprofessional primary health-care service delivery and a supportive change management strategy has been partially completed. Many respondents stated that a clear policy direction was not in place in their organization, CANADIAN NURSES ASSOCIATION 15

18 and even more noted that a change management strategy had not been implemented. Some respondents described significant progress in this area, such as the development of models, and some indicated a need for more action. This area is critical to the integration of NPs and should be the focus of further investigation. Action 23, which concerns liability protection and interprofessional team liability coverage, has been partially completed. Issues of liability protection have been clarified (refer to Role Clarity, under the legislation and regulation strategic area). As indicated, most NPs now have a minimum of $5 million in liability protection as part of their registration. However, as new team models develop, more consideration needs to be given to ensuring adequate liability coverage for all members of the health-care team especially in the case of small employers in which a physician is the employer, and where NPs act as independent contractors. In response to the questionnaire, CNPS reported that there is no mechanism in Canada to track claims and payments made against health-care providers; it also indicated that each insurance company has its own database and information from these databases is not shared or disclosed for corporate security and competition issues. Progress on this action is unlikely to occur. Action 24, which concerns P/T government coverage of the cost of professional practice and liability protection, has been partially completed. The liability protection for NPs is covered by the employer and the NP registration application fees. STRATEGIC AREA: Health Human Resource (HHR) Planning Recommendations 3 to 7 are included in this strategic area, along with 12 actions. RECOMMENDATION 3 Conduct needs-based HHR planning for NPs using a pan-canadian, interprofessional approach that is based on a conceptual framework. To support this planning, use the Health Human Resources Planning Simulation Model for NPs in Primary Health Care. TM Key Actions Status Report 26. Secure long-term sustainable investment for the development of comprehensive Partially valid and reliable data to support HHR planning. completed 27. Develop a minimum data set to use the model. Not completed Representatives of provincial nursing associations and governments were questioned about Action 26. Respondents reported that this action has not been completed except in one jurisdiction. However, there are many strategies established to recruit and retain NPs in some of the jurisdictions. CNA has not developed a minimum data set to use the model owing to a lack of resources. 16 RECOMMENDATIONS OF THE CANADIAN NURSE PRACTITIONER INITIATIVE: PROGRESS REPORT

19 RECOMMENDATION 4 Adopt funding models for primary health-care services that reflect a needs-based system (including health status) that supports interprofessional practice and incorporates population health outcomes. Key Actions Status Report 28. Develop and disseminate a toolkit on organizational and funding model options. Not completed All respondents from F/P/T governments reported that the Development of Health Human Resources Planning Simulation Model for Nurse Practitioners in Primary Health Care (CNA, 2006c), developed as part of the CNPI, is not used. One respondent noted that their organization did not have the capacity to populate and sustain the model; another reported that the simulation model was tested and resulted in unsuccessful outcomes due to unavailable data. There were no comments to explain why the tool is not being used by government. There is some evidence from the comments that some NPs educated to provide primary care cannot find employment consistent with their educational preparation. This indicates that HHR planning for NPs (and other members of the interprofessional primary care team) may need more attention. As of January 2009, the number of NPs in Canada had doubled since This is a significant increase, and investment in HHR planning methods that would guide further development would appear to be timely. Some respondents commented that CIHI should collect data on the registration category of NPs. Such a step would assist stakeholders in determining which areas of the country are experiencing the fastest growth in NP registrations. The need to develop appropriate funding models to promote interprofessional practice in primary care was raised in response to a number of questions in the questionnaires. RECOMMENDATION 5 Remunerate NPs to reflect their scope of practice, responsibility and accountability, and standardize the remuneration to address: salary/benefit discrepancies (within provinces and territories); yearly cost-of-living expenses; incentives and supports to recruit NPs to difficult-to-recruit areas; and additional overhead/operating/infrastructure expenses. Key Actions Status Report 29. Develop and distribute a remuneration guide for NPs/employers as a supplement Not to the CNPI Implementation and Evaluation Toolkit for Nurse Practitioners completed in Canada. Respondents from CNA jurisdictional members, CAAPN, NP associations and CNA commented that more clarity is needed on this recommendation, the required actions and appropriate lead(s) for the actions. Governments are usually responsible for overall funding and remuneration guidelines for health-care providers. In the implementation plan, Action 29 (development of a remuneration guide) was assigned to CNA. It has been determined that CNA should not have been the lead for this action. CANADIAN NURSES ASSOCIATION 17

20 RECOMMENDATION 6 Utilize NPs across all health-care settings in urban and rural/remote/isolated areas. NP practice should be a blend of individual and family visits, population health activities and other advanced practice activities (research, leadership, collaboration and change agent). Key Actions Status Report 30. Advocate to employers/governments for use of NPs in all settings using NPs in Action ongoing home care and long-term care fact sheets. 31. Amend labour contracts to protect time for all activities. Partially completed 32. Create centralized web-based location for posting of available NP positions. Not completed 33. Educate employers on requirements for licensure in terms of all activities. Action ongoing CNA, representatives of regulatory bodies and CNA jurisdictional members, CAAPN, NP associations and CFNU were questioned about the actions associated with Recommendation 6. Respondents reported that regulatory models are in place in most jurisdictions to allow the use of NPs in all health-care settings, and that regulators are providing information to employers on the requirements for licensure. Respondents raised concerns related to the inadequacy of positions for NPs in primary care. CNA is planning a web-based location for the posting of available NP positions. RECOMMENDATION 7 Create healthy work environments for NPs that support positive client, provider and system outcomes. Key Actions Status Report 34. Raise awareness and seek commitment from ACHDHR 4 on need for workload Not completed measurement methodologies. 35. Promote infrastructure/technologies to support distance education. Action ongoing 36. Develop or strengthen existing F/P/T NP associations to provide professional Partially networks and mentorship programs. completed 37. Encourage the development of incentives, supports and innovative learning Action approaches to support the initial and continuing education of NPs, including ongoing in urban, rural/remote/isolated and aboriginal communities. 4 Advisory Committee on Health Delivery and Human Resources 18 RECOMMENDATIONS OF THE CANADIAN NURSE PRACTITIONER INITIATIVE: PROGRESS REPORT

21 Representatives of CAAPN, NP associations, regulatory bodies and P/T governments described significant support for continuing education, including opportunities for distance education (see also Actions 68 and 69). A high percentage of NP respondents reported receiving monetary support from their employer for the cost of continuing education, as well as paid release time, although there is variation in the level of support provided. NP associations are focusing on the development of professional networks and educational opportunities for their members. As small, volunteer-run organizations, they do not have the capacity to develop formal mentorship programs. There has been little action on the development of appropriate workload measurement methodologies. Representatives of the F/P/T governments were asked to describe their recruitment and retention strategies. Recruitment strategies included undertaking initiatives that were part of overall strategies for nurses or for all health-care providers; focusing on finding work for graduates in the province; providing relocation assistance and grants to encourage NPs to move to hard-to-recruit areas; and providing mentoring opportunities for new graduates. Retention strategies included providing consultative support to regional health authorities as they implement NP roles with the goal of creating working environments that provide appropriate supports for practice and that use NPs optimally; involving multiple stakeholders; using quality practice environment tools and CNPI information; and offering full-time work and good remuneration to NPs. STRATEGIC AREA: Education RECOMMENDATION 8 Adopt the Education Framework for Nurse Practitioners in Canada. The education strategic area included Actions 38 to 70 from the implementation plan. Key Actions Status Report Guiding Philosophy, Assumptions and Values 38. Reflect the guiding philosophy, assumptions and values found in the Education Status not Framework for Nurse Practitioners in Canada. investigated Entry to Nurse Practitioner Educational Programs 39. Establish admission criteria that include an active RN designation and a Completed minimum of two years of full-time equivalent clinical nursing experience. 40. Adopt and apply the principles found in the Prior Learning Assessment and Partially Recognition Framework for Nurse Practitioner Education and Regulation in completed Canada (CNA, 2006e). CANADIAN NURSES ASSOCIATION 19

22 41. Establish a pan-canadian approach to transfer of credits. (Note: Educational Not completed institutions were asked about their transfer of credit policy in a question (see Action 42) relating to Action 42.) 42. Allow for the transfer of credits between educational institutions subject to Completed maximums established by the institutions. Curriculum Alignment and Linkages 43. Develop philosophy, mission and goal statements that are aligned with Status not pan-canadian frameworks governing NP education, and periodically assess investigated and review them. 44. Establish and promote participation in a pan-canadian accreditation process Not completed for NP educational programs. 45. Develop linkages between accreditation and approval processes. Not completed 46. Be responsive to broadly defined, evidence-based stakeholder needs. Status not investigated 47. Be consistent with the Canadian Nurse Practitioner: Core Competency Framework Completed (CNA, 2005b) and the standards inherent in the NP program approval process. 48. Adopt the master s degree (MN/MScN) as the required exit credential, ideally Partially by 2010, but no later than completed 49. Develop and institute bridging mechanisms to support program transition to Not completed a graduate degree (MN/MScN) as the standardized exit credential. 50. Develop and institute bridging mechanisms to support an individual s Partially transition to a graduate degree. completed Nurse Practitioner Education Delivery 51. Where practical, designate PhD-prepared practising NPs to teach NP-specific Completed courses. Where limited, facilitate access to PhD preparation, engage qualified masters-prepared NPs or non-nps, and/or use team teaching or shared resource models. 52. Recognize NP faculty clinical hours as teaching hours. Partially completed 53. Establish and monitor guidelines governing NP educational program Completed faculty-student ratios. 54. Establish 700 hours as the standard minimum number of clinical practice hours. Completed 20 RECOMMENDATIONS OF THE CANADIAN NURSE PRACTITIONER INITIATIVE: PROGRESS REPORT

23 55. Require clinical preceptors to be an NP or an advanced practice nurse or Completed equivalent subject matter expert in a relevant professional discipline with a sound understanding of the NP role. 56. Initiate a coordinated effort to sustain and increase the supply of available Partially preceptors. completed 57. Develop preceptor preparation programs. Status not investigated 58. Develop pan-canadian standards for NP distance education. Not completed 59. Develop and deliver distance education courses for NPs. Completed 60. Develop innovative approaches to support collaborative programming and Partially pursue and implement funding for collaborative programming approaches. completed 61. Develop and offer interprofessional courses. Partially completed 62. Implement evidence-based student evaluation and testing methodologies. Status not investigated 63. Establish a pan-canadian resource bank, including approaches and tools. Status not investigated Licensure to Practice 64. Implement cross-jurisdictional collaboration among schools and regulatory bodies Status not to ensure that the licensure-to-practice process for NP students is supported by investigated NP educational program content and teaching and learning processes. Transition to the Workplace 65. Develop and implement processes and structures to facilitate the transition of Partially NPs from their educational program to the workplace and from novice to expert. completed 66. Establish mentorship and a mentorship culture as standard features of the NP Completed learning experience. 67. Develop pan-canadian mentorship tools and promote their use across all NP Not completed educational programs and in the workplace. 68. Create and support a culture of continuous learning among students and Action ongoing practising NPs. 69. Remove potential barriers to continuing education, including funding, time off, Partially and access to learning opportunities. completed 70. Develop refresher training programs, as required, for re-entry to practice. Not completed CANADIAN NURSES ASSOCIATION 21