A Regulatory Framework for Nurse Practitioners in British Columbia

2855 Arbutus Street Vancouver, BC V6J 3Y8 Tel 604.736.7331 1.800.565.6505 www.crnbc.ca A Regulatory Framework for Nurse Practitioners in British Columbia In 2000, the Ministry of Health (the Ministry) announced its decision to introduce nurse practitioners into the British Columbia health care system. The aim was to improve public access to health care services in B.C. The Ministry and the College of Registered Nurses of British Columbia 1 (the College) partnered in this initiative. The College began registering nurse practitioners in 2005. The College was responsible for: developing competencies and necessary processes to register nurse practitioners, including establishing initial and renewal registration requirements, and setting standards, limits and conditions for nurse practitioner practice. The Ministry was responsible for: drafting regulations setting the scope of nurse practitioner practice, addressing employment issues, and supporting development of nurse practitioner educational programs. The Ministry and the College agreed on eight principles to guide the implementation of nurse practitioners in the B.C. health care system. See Appendix A for the principles. rigorously regulate nurse practitioners. This would help protect public safety and demonstrate to the public and other stakeholders that the regulatory body appropriately and effectively regulates the practice of nurse practitioners. Consultations made clear that safe practice would be better achieved through substantive regulatory requirements implemented by the nursing regulatory body than by having government set narrow limitations on the scope of nurse practitioner practice. This approach lets the College determine acceptable practices within broadly framed legislation. Rigorous regulation of nurse practitioners requires policy and processes in three interdependent areas: 1. competencies and recognition of nurse practitioner education programs; 2. initial registration requirements; and 3. practice oversight, including setting standards, limits and conditions and establishing a quality assurance program. The approaches outlined in this document are set out in the College s bylaws and policies. Normally, bylaws have a three-month consultation period. The majority of bylaws require approval by the Minister of Health before they can be implemented. Throughout the development of the regulatory framework, stakeholders stressed the importance for the College to 1 Until August 2005, CRNBC was formerly known as the Registered Nurses Association of British Columbia. COLLEGE OF REGISTERED NURSES OF BRITISH COLUMBIA P a g e 1

C OMPETENCIES AND RECOGNITION OF EDUCATIONAL PROGRAMS The first area required for regulation of nurse practitioners is the establishment of required competencies and the recognition 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 2003 and revised in 2010. See Competencies Required for Nurse Practitioners in British Columbia at www.crnbc.ca. Nurse practitioners are health care professionals who have achieved the advanced nursing practice competencies at the graduate level of nursing education that are required for registration as a nurse practitioner with the College. They provide health care services from a holistic nursing perspective, integrated with the autonomous diagnosis and treatment of acute and chronic illnesses, including prescribing medications. The College registers nurse practitioners in one of three categories of practice: family, adult and pediatric. Family The nurse practitioner (family) is educated to provide health care services to all ages including: newborns, infants, toddlers, children, adolescents, adults, pregnant and postpartum women, and older adults. Pediatric The nurse practitioner (pediatric) is educated to provide health care services to children including: newborns, infants, toddlers, children, and adolescents. Nurse practitioner (family) competencies include acute health conditions, diseases and disorders, mental health, chronic illness and geriatrics at the primary care level. These are important issues in primary care. The NP (adult) and (pediatric) are prepared with the same primary care competencies for the care of their populations as the NP (family) and then develop more extensive knowledge about their respective populations than nurse practitioners (family). For example, preparation for the nurse practitioner (adult) includes competencies to care for frail older people with complex care needs and co-morbidities. For a more detailed description of the areas of practice and a profile of the newly graduated nurse practitioner in each area see Competencies Required for Nurse Practitioners in British Columbia. The document is available at www.crnbc.ca. The College uses the same process in recognizing education programs for entry-level nurse practitioners and entrylevel registered nurses. The College s bylaws and board policies set out the process. Programs recognized by the College are listed in Schedule C of the bylaws. The bylaws are posted at www.crnbc.ca. Adult The nurse practitioner (adult) is educated to provide health care services to young, middle-aged and older adults. COLLEGE OF REGISTERED NURSES OF BRITISH COLUMBIA P a g e 2

INITIAL RE GIS TRATION OF NURSE PRACTITIONERS Initial registration is the second area required for regulation of nurse practitioners. There are four requirements for initial registration as a nurse practitioner in B.C.: 1. Current practicing registration as a registered nurse in B.C. or eligibility for registration as a registered nurse in B.C. 2. Successful completion of a CRNBC-recognized nurse practitioner program or successful completion of a nurse practitioner program equivalent to a Master s level nursing education program that prepares graduates with the competencies to practice as described in the Competencies Required for Nurse Practitioners in British Columbia. 3. Successful completion of both a written and a clinical examination. 4. Evidence of meeting the College s nurse practitioner practice hours requirement. Applicants for nurse practitioner registration who did not complete a recognized nurse practitioner program in B.C. have their educational preparation and practice assessed to determine if they are eligible to take required nurse practitioner examinations. If gaps are found, applicants may acquire additional competencies through an educational program, and/or if they meet certain criteria, apply for a more detailed competency assessment. The detailed competency assessment involves: 1. case study examples; 2. interview/panel assessment; and 3. supervised clinical practice. Read more on the application process at www.crnbc.ca. Note: In B.C. both nurse practitioners and certified practice RNs are authorized under the Nurses (Registered) and Nurse Practitioner Regulation to diagnose diseases and disorders and treat with prescription medications. However, there are significant differences in the education and scope of practice of nurse practitioners and certified practice RNs. Appendix B contains a comparison table. All nurse practitioner registration applicants must pass two examinations a written examination and an objective structured clinical examination (OSCE). The College chose the American Nurses Credentialing Center (ANCC) examinations (family, adult, pediatric) for the written examination requirement. The College also accepts these examinations as equivalent to those of the ANCC: - The American Academy of Nurse Practitioners (AANP) in family is equivalent to the ANCC examination in family; - The American Academy of Nurse Practitioners (AANP) in adult is equivalent to the ANCC examination in adult; - The Pediatric Nursing Certification Board (PNCB) nurse practitioner certification exam is equivalent to the ANCC examination in pediatrics. The College developed an OSCE for each category of practice (family, adult, pediatric). The OSCE is a structured performance test based on a series of separate testing stations that use standardized patients (SPs). These patients are called standardized because their presentation of the role is standardized through training. The SPs are typically trained lay people who provide real-life interactions with the candidate. Nurse practitioners score the candidate s performance using structured marking sheets. Scores from well-designed and administered OSCEs are highly valid and reliable, based on psychometric analyses reported in peerreviewed literature. The OSCE format allows testing of broad competencies such as: history taking, physical examination, ability to perform procedures, clinical reasoning, COLLEGE OF REGISTERED NURSES OF BRITISH COLUMBIA P a g e 3

diagnosis, treatment or therapeutic management, patient education, and communication skills. The College s Nurse Practitioner Examination Committee directs the development of the OSCEs and scores the OSCE and the written examinations. The College s bylaws set out the Committee s membership and duties. Other professions, such as medicine, pharmacy, and physiotherapy, require an OSCE as part of initial registration. Recognition of nurse practitioner education programs is seen as a key component to ensure that applicants have appropriate competencies. However, the examinations, both written and OSCE, were identified by the College as a necessary part of the regulatory responsibility to verify competencies of the individual applicant. The educational program recognition process is focused on aggregate information spanning up to seven years, the maximum length of program recognition. It does not examine in-depth or directly the achievement of individual graduates. The College developed Applying the Competencies Required for Nurse Practitioners in British Columbia. This document provides further specifics about the Competencies Required for Nurse Practitioners in British Columbia to enable CRNBC to establish objective criteria for purposes of assessment or evaluation of individual nurse practitioner applicants or registrants. Such assessments include the competence assessment process, the OSCE and the Quality Assurance Program. O VERSIGHT 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., quality assurance). The College s Nurse Practitioner Standards Committee recommends to the Board standards, limits and conditions 2 for nurse practitioner practice. The committee s responsibilities are set out in the Nurses (Registered) and Nurse Practitioner Regulation and the College s bylaws. The committee consists of: 1. two physicians and a pharmacist who have worked with nurse practitioners, 2. a government representative, 3. a public member and 4. seven registered nurses or nurse practitioners (including a representative from the education programs that prepare nurse practitioners). The committee s composition supports transparency and openness to the views of others while maintaining the principle of self-regulation. Nurse practitioners are required to meet standards, limits and conditions as one part of the requirements for initial and ongoing registration as a nurse practitioner. The standards, limits and conditions, together with the Competencies Required for Nurse Practitioners in British Columbia are used in the recognition process for nurse practitioner education programs in B.C. Nurse Practitioners have a scope of practice beyond that of registered nurses. This requires additional regulation by the College. Under the Health Professions Act regulatory colleges establish continuing competence requirements, and pending amendments to the Health Professions Act, will require all colleges to establish quality assurance programs. 2 See the document Scope of Practice for Nurse Practitioner: Standards, Limits and Conditions. Available on the website. COLLEGE OF REGISTERED NURSES OF BRITISH COLUMBIA P a g e 4

Quality assurance requirements are posted at www.crnbc.ca. Nurse practitioners comply with the CRNBC Quality Assurance Program requirements for registered nurses. These requirements include completing a self- assessment, obtaining peer feedback, professional development planning and evaluating professional development. Nurse practitioners requirements relate to standards and their competencies for practice. Nurse practitioners must submit information annually. Under provisions in the Health Professions Act, the Board has approved requirements for an on-site peer review of practice. The intent is to review practice and provide support and, where necessary, direction in meeting Standards and maintaining the competencies for nurse practitioner practice. The quality assurance practice review also identifies system-related issues. The quality assurance practice review occurs within the first two years of practice for each new nurse practitioner registrant in B.C. and subsequently occurs at least once every five years. The College conducts ongoing review of NP oversight processes to ensure that these are comprehensive in describing and assessing NP scope of practice. Issues related to complaints about a nurse practitioner s practice are addressed in the College s bylaws on inquiry and discipline under the Health Professions Act. The College has systems in place to handle complaints about registered nurse practice. These systems were expanded to address complaints about nurse practitioner practice. The Health Professions Act introduced mandatory reporting, another regulatory tool. All health professionals must 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. C ONCL USION The key principle underlying College decisions is that they are made in the public interest. It is essential that nurse practitioners can practice with autonomy and flexibility to safely meet the public s health care needs. The College is confident that this rigorous regulatory framework provides the tools to appropriately and effectively regulate the practice of nurse practitioners. Copyright College of Registered Nurses of British Columbia /March 28/13. COLLEGE OF REGISTERED NURSES OF BRITISH COLUMBIA P a g e 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 practice 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 outdated. By building flexibility into the legislative model for nurse practitioner regulation in B.C., the reality of different practice environments can be accommodated. COLLEGE OF REGISTERED NURSES OF BRITISH COLUMBIA P a g e 1

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 competence- based. 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. *Note the College s Board decided that only applicants for nurse practitioner registration who graduate from a formal nurse practitioner program will be assessed for nurse practitioner registration. Adapted from the Ministry of Health s Consultation Paper: Nurse Practitioner Project (February 2002) COLLEGE OF REGISTERED NURSES OF BRITISH COLUMBIA P a g e 2

APPENDIX B: COMPARISON OF CERTIFIED PRACTICE RN AND NURSE PRACTITIONER AREA OF COMPARISON General description Primary Care Provision Education Approval/Recognition of Educational Programs/Courses Registration Scope of Practice- Regulation Scope of practice further defined by CRNBC CERTIFIED PRACTICE RN - RN(C) RN(C)s autonomously carry out activities outside the scope of practice of RNs in BC in limited circumstances set out in decision support tools. RN(C)s autonomously provide some primary care services to clients. They are not prepared to be a primary care provider. Time limited educational courses: weeks to 3-4 months The Nurses (Registered) and Nurse Practitioner Regulation states that the certification must be established or approved under the CRNBC Bylaws to ensure that registrants are qualified and competent to practice. CRNBC approves: - Diseases and disorders within the certified practice category and the associated competencies - Decision support tools - Certified Practice Courses Approval is done by the CRNBC Board on the recommendation of the Certified Practice Approval Committee RNs who successfully complete an approved certification course can apply to have their name listed on a certified practice register accessed through the CRNBC website RN scope of practice is set out in Section 6 and 7 of the Nurses (Registered) and Nurse Practitioner Regulation. Additional scope of practice for RN(C)s is set out in Section 8 of the Nurses (Registered) and Nurse Practitioner Regulation. The limits of practice of RN(C)s are set out in decision support tools approved by the CRNBC Board on the recommendation of the Certified Practice Approval Committee. NURSE PRACTITIONER - NP NPs autonomously carry out a wide variety of activities beyond the scope of practice of RNs in BC with a high degree of independent judgment. NPs are able to serve as the primary care provider for an established group of clients Nurse practitioners achieve advanced nursing practice competencies in a two year program at the graduate level of nursing education. CRNBC recognizes NP programs on the basis of nursing education standards and indicators pertinent to the CRNBC entry level NP competencies and the Standards of Practice. Recognition is done by the CRNBC Board on the recommendation of the Education Program Review Committee. NPs who meet the requirements for NP registration are registered by CRNBC in the nurse practitioner class. The list of registered NPs is accessed through the CRNBC website Additional scope of practice for NPs is set out in Section 9 of the Nurses (Registered) and Nurse Practitioner Regulation NPs practice in accordance with Standards, Limits and Conditions established by the CRNBC Board on the recommendation of the Nurse Practitioner Standards Committee. COLLEGE OF REGISTERED NURSES OF BRITISH COLUMBIA P a g e 1

AREA OF COMPARISON Diagnosis Ordering Diagnostic Tests Prescribing Types of Practice CERTIFIED PRACTICE RN - RN(C) Diagnosis of a limited number of diseases and disorders by the RN(C) is guided by decision support tools approved by the CRNBC Board. RN(C)s can order diagnostic tests that are referenced in the CRNBC Board approved decision support tools. RN(C)s may be assigned MSP numbers. RN(C)s have the authority to administer or dispense without an order a limited number of prescription drugs listed in the Board approved decision support tools. The drugs are provided through the employer. There are four categories of RN(C)s - RN First Call - Remote Nursing - Reproductive Health-Sexually Transmitted Infections - Reproductive Health- contraceptive management NURSE PRACTITIONER - NP NPs carry out differential diagnosis of a wide range of diseases and disorders. NPs have the authority to order a wide range of diagnostic tests and make referrals to specialists and family physicians. NPs are assigned MSP numbers. NPs have the authority to prescribe drugs as set out in the NP Scope of Practice Standards. CRNBC registers NPs in three streams of practice: - Family - Adult - Pediatric Glossary Decision support tools: Evidence based documents used by registered nurses to guide the assessment, diagnosis and treatment of client specific clinical problems. Primary Care Provider: Primary care providers are health professionals who take primary responsibility for an established group of patients for whom they provide: longitudinal person-focused care; comprehensive care for most health needs; first contact assessment for new health care needs; and referral and coordination of care when it must be sought elsewhere. A primary care provider is ideally chosen by an individual to serve as his or her health care professional to address a wide variety of health care issues including health promotion, illness and injury prevention and the diagnosis and treatment of illness and injury. Additional Information Wearing, J.; Black,J; Kline, K. (2010). A Model for Nurse Practitioner Registration: Principles Underpinning a Three Categories Approach. Nursing Leadership, 22(4), 40-49. Wearing, J. and Nickerson,V. (2010). Establishing a Regulatory Framework for Certified Practices in British Columbia. Journal of Nursing Regulation, 1(3),38-42. COLLEGE OF REGISTERED NURSES OF BRITISH COLUMBIA P a g e 2