Health Committee on April 8th, 2014

[The Chair, Conservative, Ben Lobb]

Good morning ladies and gentlemen. We're back again on our study on this nice, rainy morning, but it's better than snow.

Once we're through with our witnesses we have about 10 or 15 minutes set aside at the end of our committee meeting, when we'll go in camera to discuss committee business. We'll ask our guests to leave at that time. We'll probably end about 15 minutes early so that we can have about 10 minutes for committee business.

We have a number of great witnesses today.

We have Judy Morrow from the Canadian Association of Practical Nurse Educators. We also have Debbi Templeton. Share your time as you see fit.

Just so that everybody knows, you have 10 minutes or thereabouts to do your presentation. If you have any questions, ask at any time.

[Judy Morrow, Board Member, Canadian Association of Practical Nurse Educators]

Good morning, Mr. Chair and members of the committee.

My name is Judy Morrow. I am the provincial program manager for the practical nursing education program in Nova Scotia. With me is Debbi Templeton, coordinator of health programs, from New Frontiers School Board in Ormstown, Quebec. We are here this morning representing the Canadian Association of Practical Nurse Educators, or CAPNE.

I would like to thank the committee for the opportunity—

[Terence Young, Conservative, Oakville, ON]

I have a point of order, Mr. Chair.

Excuse me, Ms. Morrow. I beg your pardon.

[The Chair, Conservative, Ben Lobb]

Yes, Mr. Young.

[Terence Young, Conservative, Oakville, ON]

I'd like to ask for unanimous consent to get the presentations from the witnesses here today. I realize that they're only available in English, and it's nobody's fault, but it would be much easier to get more out of this meeting if we had them.

[The Chair, Conservative, Ben Lobb]

Do we have unanimous consent?

[An hon. member]

No.

[The Chair, Conservative, Ben Lobb]

Okay.

I'm sorry, Mr. Young.

Carry on, Ms. Morrow.

[Judy Morrow]

I'd like to thank the committee for the opportunity to comment and provide input on behalf of the Canadian Association of Practical Nurse Educators this morning.

The Canadian Association of Practical Nurse Educators, or CAPNE, was formed in 2000, with the initial meeting held in Manitoba. At that meeting there were practical nursing educators and licensed practical nursing regulatory bodies from each province and territory, with the exception of Quebec.

CAPNE is the national voice for practical nursing education in Canada, with representation on the board from all provinces and territories. CAPNE's objectives include supporting and enhancing the quality, effectiveness, and consistency of practical nursing education across Canada.

In support of our strategic goals, a national educators conference is organized annually and takes place in a different province each year. These conferences have been very successful, with an average of about 120 participants from across Canada in attendance and much great feedback from attendees. The venue provides the opportunity for practical nursing educators to get together, to collaborate, to share best practice stories, and to gain a clearer understanding of the big picture of practical nursing education across the country, as well as learn and understand more clearly the role of the licensed practical nurse, or registered practical nurse, as it is called in some provinces.

Over the years, some common themes have been identified as issues, or barriers, perhaps, by practical nurse educators across Canada. I will speak to some of those now.

The first is the difficulty in obtaining appropriate clinical education sites in which LPNs, the licensed practical nurses, or RPNs, registered practical nurses, work to full scope of practice, especially in mental health and maternal child nursing areas in some jurisdictions.

Second, with increased competition for clinical sites, simulation has been seen as a way to augment clinical experience, but not everyone has access to good simulation labs or good equipment, because of the cost of set-up and maintenance. Simulation in more remote areas of the country may not be readily available, and this is seen as a barrier in some instances.

The third is difficulty in obtaining clinical instructors. These positions are on a part-time casual basis, and it's difficult to attract qualified nurses for short-term casual work.

Then we raise the issue of the role of clarity. The role of the practical nurse may vary from setting to setting and from province to province in terms of the ability to work to their full scope of practice. Often, fellow health care staff do not fully understand the role of the LPN or RPN, because the role can vary a great deal depending upon the setting in which the individual is working.

In Ontario, for example, the Nursing Act identifies scope of practice for an RN and an RPN in the same statement, noting that nursing is one profession with two categories. From this, some argue, the scope of practice statement for nursing in Ontario is the same, which technically it is. Confusion can arise when “scope of practice” is being defined and used in two different ways. We feel it would be helpful to have more clarity in terminology, and on a national scale.

While role clarity is sometimes fuzzy for the LPN or RPN, there are many provincial differences and there is possibly more confusion in respect to the role of the unregulated health care worker. This can cause much confusion at the national level whenever we talk about the LPN and RPN role in terms of delegation to the unregulated worker.

Some areas identified as important in the future of practical nursing education as we move forward include: first, providing opportunities for inter-collaborative education, for example, forming teams of students from different disciplines to work collaboratively within their respective roles and scopes of practice in a clinical experience so as to bring about positive outcomes in meeting their learning goals; second, exploring the possibility for students and/or faculty to exchange between provinces and other regions of Canada in order to gain a broader national perspective; third, having continuing opportunities for international placements for practical nursing students in order for them to work inter-collaboratively and develop cultural competence and learn first-hand about health care standards, the role of the health care team, and health care issues that affect populations outside of Canada.

Continuing to support the transition of internationally educated nurses into the Canadian nursing system is identified as very important and has been a standing agenda item for our board for some time. This offers many benefits. I believe we all see that the nursing shortage will likely happen. It hasn't to the extent we anticipated some time ago, but it's inevitable that it is about to happen, given the age of the nursing population at this point.

For example, data for Nova Scotia from the Canadian Institute for Health Information's “Regulated Nurses, 2012” report shows a decrease in the overall number of licensed practical nurses of 1.5% from 2011 to 2012, with the average age of the LPN in the province being 45 years. On par with the RN population age, many LPNs can retire in the next few years. In addition to filling the gap in much-needed nursing positions, well-educated and experienced IENs, internationally educated nurses, help make our health care system more culturally diverse. As our population ages, these individuals, IENs in other words, will play an important role in sustaining Canada's health care system.

An issue brought forward in Quebec is that all nurses there who are internationally educated must have English proficiency, of course, as they do in every other province, but they must also have French proficiency. Under current legislation, graduates of nursing programs have to obtain a licence in the province from which they graduated before they can move on to become licensed in another province. Without passing the French exam, they cannot be licensed; therefore, they cannot move on to another province or become licensed in another province. This extra layer can certainly limit the internationally educated nurse's success.

In conclusion, on the topic of internationally educated nurses, I'd like to share with you a best practice story from my province, Nova Scotia. Over the past four years the College of Licensed Practical Nurses of Nova Scotia, CLPNNS, in partnership with the Nova Scotia Community College, NSCC, and with funding from the Nova Scotia Office of Immigration, has developed and implemented a program for internationally educated nurses. This program is called the pathway to success. The program builds on the internationally educated nurse's education and experience, leading to a credential as a licensed practical nurse and employment in Nova Scotia.

Since 2010 CLPNNS has licensed 113 IENs as LPNs in Nova Scotia, and today approximately 90% are currently employed in Nova Scotia. In March the pathway project received the 2014 International Qualifications Network, IQN, innovation award at the awards ceremony held in Ottawa. We currently have funding for this project until the end of June, and we're looking forward to meeting the educational requirements of possibly up to 20 more internationally educated nurses in that timeframe.

Thank you very much for your time this morning.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Next up, from the Canadian Nurses Association, are Dr. Barbara Mildon and Josette Roussel.

Go ahead, for 10 minutes please.

[Dr. Barbara Mildon, President, Canadian Nurses Association]

Thank you for inviting the Canadian Nurses Association to be part of today's proceedings.

I am Barb Mildon, president of CNA. I am pleased to be joined by Josette Roussel, who is a senior nurse consultant at CNA. I am a certified community health nurse and have worked in clinical and management positions in both B.C. and Ontario for many decades. My current role is vice-president of professional practice, human resources and research, and chief nurse at the Ontario Shores Centre for Mental Health Sciences in Whitby, Ontario.

CNA is the national professional voice of registered nurses in Canada. We support registered nurses in their practice, and we advocate for healthy public policy and a quality, publicly funded, not-for-profit health care system. A federation of 11 provincial and territorial nursing associations and colleges, CNA represents more than 150,000 registered nurses and nurse practitioners across the country.

Today we will share some information about registered nurses in Canada, provide an overview of the factors affecting nursing scope of practice in Canada, present a best practice example, and three recommendations on ways the federal government can support efforts to optimize the roles of nurses through legislation and as an employer of nurses.

In Canada there are three regulated nursing professions: registered nurses, licensed practical nurses, and registered psychiatric nurses. For registered nurses three national groups actively support the profession: CNA, the Canadian Nurses Association, is the professional voice; the Canadian College of Registered Nurse Regulators is the regulatory or licensing voice; and the Canadian Federation of Nurses Unions advances the socio-economic concerns of nurses in the country.

Registered nurses are the largest regulated health profession in Canada. According to the Canadian Institute for Health Information, there were 356,422 regulated nurses working in Canada in 2012. These break down into 292,883 RNs, 99,935 licensed practical nurses, which my colleagues have already explained are called registered practical nurses in Ontario, and 5,528 registered psychiatric nurses, who exist only in Canada's four western provinces and the Yukon. We have over 4,000 nurse practitioners across the country. Over 60% of registered nurses work in acute care settings, 15% in community health care, and nearly 10% work in long-term care.

CNA defines scope of practice as those activities that registered nurses are educated in and authorized to perform as set out in legislation and complemented by the standards, guidelines, and policy positions of provincial and territorial nursing regulatory bodies.

There are four specific controls on nursing scope of practice. First, legislation by provincial and territorial governments establishes the broad scope of nursing practice. Second, the requirements for education, standards of practice, and continuing competence are established by the nursing regulatory colleges or associations. Third, the individual nurse assesses his or her competence to carry out an activity within his or her scope of practice. Finally, there are the settings in which the nurse practices, including the requirements of the employer, and the needs, which of course are front and centre, of patients and clients.

In Canada the federal, provincial, and territorial governments also have acts and regulations which augment the nursing acts. All of these influence the scope of RN practice. For example, the federal Controlled Drug and Substance Act describes the drugs that RNs and nurse practitioners can administer. There are the jurisdictional acts and regulations related to RNs pronouncing death in long-term care facilities.

For a best-practice example that illustrates scope and limitations we can look to the British Columbia Nurses (Registered) and Nurse Practitioners Regulation, section 6, which states that registered nurses may carry out wound care without an order. I

n B.C., that means a nurse can cleanse, irrigate, probe, debride, pack, and dress wounds. However, many jurisdictions do not allow for this autonomous practice and still require an RN to have a doctor's order to do this activity. Even though B.C. has an expansive and defined regulation for autonomous scope of practice activities, there are employers in B.C. who may not allow RNs to perform this activity, which is another barrier to RNs working to full scope.

CNA believes that safe nursing practice in the interest of the public and optimal deployment and retention of registered nurses are best served when provincial and territorial governments and their nursing regulatory bodies adopt a comprehensive regulatory framework that reflects the reality of RN practice and clear responsibility and accountability mechanisms for scope of practice activities by competent nurses.

My colleague from CCRNR will speak directly about this and the important work under way to update the regulatory framework for nursing and ultimately support the harmonization of regulations across Canada. My colleague from the Canadian Association of Schools of Nursing will provide similar specifics concerning education of RNs.

CNA recommends that this committee recommend to the federal government that they create a federal, provincial, territorial table to support harmonization of variations in scope of practice legislation. At this table the jurisdictional legislators, the RN regulators, educators, and employers could come to consensus on how to adjust legislation, professional regulatory frameworks, and standards of practice so that RNs can carry out consistent and optimal scopes of practice across the country.

In this way RNs working at the top of their scope of practice can be best utilized to promote cost-effectiveness and access to care in all parts of Canada, which would also enhance the mobility of nurses throughout our country and the retention in the workforce.

We see this recommendation as building on past successful collaborations with Health Canada and the federal, provincial, territorial tables, specifically the Canadian Nurse Practitioner Initiative report in 2006 which, among other things, led to the identification of barriers and enabling factors to optimize the role of nurse practitioners across Canada. This initiative articulated legislative and regulatory barriers to full scope of practice for nurse practitioners, including the regulations needed for them to be autonomously able to prescribe controlled drugs and substances.

While the federal government enacted those regulations in 2012, less than half the jurisdictions in Canada have implemented those welcomed changes. Accordingly, we recommend that this committee identify the development of a harmonization strategy as a requirement of any collaborative work that results in expanded scope of practice.

This recommendation is also an opportunity for the federal government to optimize RN scope of practice in its role as the fifth largest employer of registered nurses in Canada. As this committee heard, RNs provide care and program support in Health Canada, Correctional Services, the Canadian Forces, Citizenship and Immigration, Employment and Social Development, and Veterans Affairs.

Harmonized recognition of RN qualifications would enhance the mobility of nurses working for the federal government, making it easier to fill federal vacancies, and would be especially helpful in enhancing emergency preparedness during times of pandemic or other public health crises. The harmonizing work under way by our regulator colleagues stands to be greatly enhanced by the creation of a dedicated federal, provincial, territorial table to support its implementation.

This leads me to CNA's second recommendation for federal government action to optimize scope of practice, namely to address the remaining barriers to implementation of the nurse practitioner role.

First, NPs should be added to the list of professionals exempted from section 14 of the Food and Drugs Act. This would enable them to distribute samples of pharmaceuticals they are already prepared and authorized to prescribe to patients. The exclusion of this authority is a direct example of a scenario where legislation needs to change to keep up with evidence-based changes to scope of practice.

Second, NPs should be recognized as health professionals who are authorized to sign claim forms for federally administered programs, such as the disability tax credit certificate, CPP disability benefits, employment insurance benefits, and benefits under the Public Service Superannuation Act.

Many jurisdictions have passed consequential amendments to provincial acts allowing NPs to assess and sign various forms. We recommend that the federal government review existing policies where physician signatures are required to determine if nurse practitioners have the knowledge and skill to be included as signatories, thereby increasing access for Canadians to timely benefits that affect their health.

To the third component of the committee's study, CNA recommends that the federal government, as an employer, support skills training and continuing education for its nurses. National specialty certification exams are offered by CNA for RNs in 20 areas of nursing practice. This credential demonstrates that an RN is qualified and competent in several elements of specialty nursing practice. Promotion and support of this credential by employers is a way for the federal government to support a best practice in skills training for RNs.

My final comments relate to the role of registered nurses in practice in Canada, which I hope will be helpful in considering interprofessional practice.

There is a universality to nursing, particularly in acute care settings, in that registered nurses are assigned to entire patient populations. While individual patients among such a population may also be assigned to a behavioural specialist or a physiotherapist, etc., to support that patient's recovery, those decisions are made on an individual basis. Nurses are the professionals responsible for providing care from morning to morning. Their involvement in care is a constant. The principles of safe staffing and effective teams demand that each person within a team understand each other's scope and role, and keep the needs of the patient at the very centre of the care.

We appreciate your consideration of these recommendations and look forward to your questions.

Thank you.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Next up is Dr. Cynthia Baker, from the Canadian Association of Schools of Nursing.

Go ahead, please.

[Dr. Cynthia Baker, Executive Director, Canadian Association of Schools of Nursing]

Good morning. My name is Cynthia Baker, and I am the executive director of the Canadian Association of Schools of Nursing.

CASN—ou l'ACESI en français—is the national voice of nursing education in Canada. On behalf of CASN, I would like to thank the health committee for inviting us here today to speak to this very important and timely study.

We are pleased to have the opportunity to present our views on this subject.

First, I will begin with some information about CASN. Second, I would like to take a quick look at my crystal ball and share with you some health care issues we see coming down the road—well, actually we see them just around the corner. We believe they have important implications for scopes of practice, health team collaboration, and nursing education. I will conclude with an area where we see the federal government playing an essential role.

First about CASN, we are a national and bilingual organization of the 91 schools of nursing offering baccalaureate and/or graduate programs of nursing in Canada. Our mandate is to promote high-quality nursing education across the country.

Currently there are a total of 53,184 students in our member schools: 48,962 of them are in baccalaureate programs, 2,776 in master's programs, 999 in nurse practitioner programs, and 447 in doctoral programs for nurses. Nursing faculty currently number 8,192 across the country.

I would like to point out that our Quebec members and francophone nursing schools outside Quebec— in New Brunswick, Ontario and Alberta—are very engaged and active.

We also have member schools in rural and remote areas of Canada, for instance, Aurora College in the Northwest Territories and Arctic College in Nunavut. Many schools of nursing have adopted special measures to ensure that aboriginal communities access their programs, and CASN works closely with the Aboriginal Nurses Association of Canada to improve the recruitment and retention of aboriginal nursing students.

What does CASN do? As part of its mandate, CASN is the national accrediting body for baccalaureate nursing education. We have formal memoranda of understanding with a number of regulatory associations linking provincial regulatory approval to pan-Canadian educational standards. Accreditation is important in ensuring pan-Canadian educational standards.

I would like to take this opportunity to add that Canadian nursing education is widely acclaimed internationally. Many actually consider it to be the best in the world. CASN is currently assisting governments in Bangladesh,

and also in Haiti,

to strengthen the quality of their respective nursing programs through accreditation and curriculum evaluation.

We develop educational guidelines, frameworks, and resources to promote high-quality nursing education across the country. For example, we have guiding principles and essential components for nurse practitioner programs and guiding principles and essential components for bridging programs for internationally educated nurses.

Other initiatives target areas of health care needing greater curricular emphasis, such as interprofessional collaboration. With help from Health Canada we develop national competencies in teaching and learning resources to build faculty capacity to teach palliative and end-of-life care. Similarly, we have created competencies and teaching toolkits to assist faculty in preparing nursing students to deliver care in technology-enabled environments.

Our methodology ensures that the frameworks are well developed, but I think that more importantly, the pan-Canadian process we use mobilizes the targeted curriculum change by engaging our membership,

including our francophone members,

building consensus nationally and producing momentum to shift education for nurses.

As a national organization working in nursing education, we often find this challenging, because education and health are largely provincial and territorial matters. However, time and time again CASN has seen the importance of a national harmonization of nursing education. A nurse may be educated at the University of Alberta but may find employment in northern B.C., rural Saskatchewan, or downtown Toronto. These environments present different nursing demands, but our nursing graduates should be prepared for all of them. CASN sees an important role for the federal government in the scope of practice, skills training, and curriculum development for health care professionals.

As to future trends—my crystal ball—the burden of disease and health care delivery is shifting as the population ages and obesity rates rise. The health care issue facing the largest number of Canadians today, we believe, is how to live with or support someone living with multiple, complex, interacting, and often incapacitating chronic conditions. Cases of dementia are also rising rapidly, and the need for palliative end-of-life care is increasing as a result of the aging of the population. As the very first baby boomers are only 67, we are seeing only the tip of the iceberg. We believe that these issues are likely to grow exponentially in the next three decades.

I know that the health committee studied chronic disease in 2012 and I have read the report with a great deal of interest. There has already been a 100% increase in home care in Canada, but the demand continues to surge. The need for long-term care facilities and hospice care is also likely to grow, even with an increase in home care. While a team of health care professionals needs to be involved, the core services are provided by registered nurses, practical nurses, and personal care workers. CASN also sees a growing role for nurse practitioners in these areas.

There is an urgent need to support community-based long-term management of chronic illness with a much better collaborative system of care in which continuity and coordination are emphasized. There is an associated need to remove scope-of-practice barriers for nurse practitioners, to support registered nurses and practical nurses in working to their full scope of practice, and to align nursing education curricula in support of this.

Notwithstanding a shift to community-based services, I would like to stress that the acute care hospital is likely to continue to be a major employer of nurses. People are hospitalized for trauma and episodic illness, but the majority have chronic conditions requiring surgery or requiring the management of symptoms that have become life-threatening, such as heart attacks.

The complexity of hospital nursing care has increased significantly because patients are much sicker than they used to be, they stay for a much shorter time, and managing the technology and the treatments, which typically falls to the nurses, is far more complex than in the past. Actually, this is true of home-based care as well.

Many well-designed studies have shown irrefutably that the education of nurses is critical to patient safety and patient outcomes. The most recent, published in The Lancet in February 2014 was conducted in nine European countries and reported that an increase in the proportion of nurses with bachelor's degrees was associated with a significant decrease in patient deaths, whereas a decrease in the share of nurses with bachelor's degrees was associated with a significant increase in patient deaths. Researchers concluded that reducing the number of appropriately educated registered nurses is often tempting but is not a wise place to cut costs.

To speak to the federal role, the federal government has supported national initiatives to promote change in health professional education in the past, and these are currently improving health care. Interprofessional education promoted by Health Canada is now incorporated in the accreditation standards of eight Canadian health professions, including ours. Palliative and end-of-life care is another good example in which it has been promoted in medicine, in medical education, in nursing education, and in the education of social workers. I think we are seeing the fruits of this.

CASN recommends that the federal government continue to improve health care by supporting national initiatives that will influence health professional education and the preparation of new practitioners. In light of the growing burden of chronic disease in Canada, we believe there is a critical need to develop a national framework to guide the future of nursing education based on an examination of the scopes of practice of nurse practitioners, registered nurses, and practical nurses, as well as intraprofessional and interprofessional collaboration as part of this framework.

Thank you.

[The Chair, Conservative, Ben Lobb]

Moving right along, now we have Paul Fisher, chairperson of the Canadian Council for Practical Nurse Regulators.

Go ahead, sir.

[Paul Fisher, Chairperson, Canadian Council for Practical Nurse Regulators]

Good morning.

Mr. Chair and members of the committee, I'm very pleased to have the opportunity to appear before you today as chair of the Canadian Council for Practical Nurse Regulators to provide an overview of the profession of practical nursing from the regulatory lens and respond to your questions pertaining to scope of practice for licensed practical nurses.

I have been a licensed practical nurse for 31 years in the province of Newfoundland and Labrador. My clinical experience has included mental health, medicine, surgery, emergency care, and community discharge planning. For the past 15 years I have been employed as the executive director and registrar of the College of Licensed Practical Nurses of Newfoundland and Labrador.

The Canadian Council for Practical Nurse Regulators is a federation of provincial and territorial members identified in legislation as responsible for the safety of the public through the regulation of licensed practical nurses. The mandate of the Canadian Council for Practical Nurse Regulators is to support the regulation of licensed practical nurses through collaboration, collectively, internally, and externally, with other provincial and territorial regulatory organizations to maintain and enhance professional relationships; to support provincial-territorial organizations with regard to decision-making, resource allocation, management issues, and individual provincial-territorial regulatory laws and resources; additionally, to support processes that allow for accountability and responsibility for decisions and which recognize the individuality of the jurisdiction; and to promote excellence in practical nursing regulation by demonstrating leadership, best practice, innovation, and professional development.

Canadians expect their health care system to provide them with safe care and to support them in becoming as healthy as possible. Meeting this expectation requires that licensed practical nurses be educated and capable of providing safe, competent, and ethical nursing care. Licensed practical nurses must demonstrate the capacity to meet jurisdictional entry-to-practice competencies and be able to practice within the context of relevant legislation and regulations while adhering to professional standards of practice and codes of ethics for the profession. Through legislation, the practical nursing profession is also granted the authority to recognize and set standards of education and standards of practice for the profession, with an obligation to protect and serve the public interest.

The practice of licensed practical nurses spans a continuum from novice to expert and may encompass clinical practice, administration, education, research, consultation, management, regulation, policy, and system development. Through their entry-level education program, licensed practical nurse experience, and continuing education activities, licensed practical nurses gain the theoretical and practical foundation to provide safe, competent, and ethical nursing care. Licensed practical nurses care for people of all ages regardless of gender, ethnicity, or social situation, and in a variety of practice settings, such as hospitals, communities, homes, clinics, schools, and residential facilities. Their practice requires knowledge about health and illness, human biological sciences, the pathophysiology of diseases, health promotion and prevention, teaching and learning, and health care systems.

Licensed practical nurses have a duty to practice safe and appropriate nursing care and to practise collaboratively with other members of the health care team. They practise autonomously within their own level of competence and seek guidance from other health care professionals when aspects of the care required are beyond their individual competence. The psychosocial components of care, including interpersonal, communication and teamwork skills, are fundamental to safe and effective practice.

Licensed practical nurses are required to practise in accordance with the standards of practice for their profession. The standards of practice are authoritative statements that define the legal and professional expectations of licensed practical nursing practice. In conjunction with the Code of Ethics for Licensed Practical Nurses, they describe the elements of quality LPN practice and facilitate mobility through interjurisdictional mutual understanding and agreement on expectations and requirements for their practice.

As members of a self-regulating profession, LPNs are personally responsible for meeting the standards of practice. The legislative responsibility for setting, monitoring, and enforcing the standards of practice lies with the provincial and territorial regulatory authorities.

The policies and practices of employing organizations do not relieve LPNs of accountability to meet these standards of practice. Where the legislation and this standards of practice document conflict, legislation will apply.

Traditionally, nurses have worked together to provide quality care, and have actively sought the responsibility for self-regulation of that care through legislative authority. As mentioned earlier, there are three groups of professional nurses in Canada: licensed practical nurses, or registered practical nurses as they're called in Ontario, registered psychiatric nurses, and registered nurses. They are responsible to their respective professional nursing regulatory bodies.

Scopes of practice continue to evolve over time due to changes in the health care environment and the health care delivery system. It is essential that there be cooperation and collaboration between and among professional nurses, the nursing regulatory bodies, government, employers, and educational institutions in order to provide guidance to nurses and ensure public safety. Regulatory bodies, in collaboration with other members, will advocate for the development of public policy that fosters health promotion and wellness.

According to the Canadian Institute for Health Information, the supply of licensed practical nurses eligible to practise in Canada grew by 23.2% between 2008 and 2012, reaching a total of 99,935. During the same period, the LPN workforce increased by more than 18%, from 74,380 to 88,211. The rate of LPNs per 100,000 population increased from 223 in 2008 to 253 in 2012.

Underutilization of the LPN scope of practice has been a long-standing issue for the profession in Canada. It is imperative that these issues be addressed. I believe the federal, provincial, and territorial governments need to change the way health human resource planning is conceptualized in Canada. It is not acceptable to regulate a profession and then permit others to arbitrarily restrict the practice of that same regulated health professional. Limiting the practice of nursing professionals to roles that are less than those enabled by educational preparation and regulatory authority wastes precious nursing human resources at a time when the health care system can ill afford it.

Ensuring that the right mix of providers is available to meet the needs of Canadians is everybody's business. Federal, provincial, and territorial governments need to ensure that licensed practical nurses are included in local, provincial, and national policy-making decisions and committees that affect nursing practice.

Licensed practical nurses have an important contribution to make in the delivery of appropriate, effective nursing services in Canada. A concerted effort is required on the part of the federal, provincial, and territorial governments to eliminate barriers that limit practical nursing student access to clinical placement practice experience and that prevent LPNs from practising to their full scope of practice within health care settings across Canada.

In closing, like many other health professionals, practical nurse regulators are very committed to having their members provide the right care to the right person by the right caregiver to optimize care and resource utilization while ensuring public safety for the provision of nursing services in Canada.

The Canadian Council for Practical Nurse Regulators is keenly interested in engaging with national and provincial professional authorities and organizations to contribute to the dialogue and to keep abreast of new initiatives that may benefit the Canadian health care system.

Thank you once again for the opportunity to be here with you today.

[The Chair, Conservative, Ben Lobb]

Thank you very much, Mr. Fisher.

Last but certainly not least is Anne Coghlan, from the Canadian Council of Registered Nurse Regulators.

Thank you for joining us this morning via video conference. You have 10 minutes, please.

[Anne Coghlan, President, Canadian Council of Registered Nurse Regulators]

Good morning, Mr. Chairman and members of the committee.

I'm pleased to present to you this morning as president of the Canadian Council of Registered Nurse Regulators.

The Canadian Council of Registered Nurse Regulators, or CCRNR, was established in 2011 as a national organization comprising the 12 provincial and territorial regulatory bodies with mandates to regulate the practice of registered nurses and nurse practitioners in Canada.

CCRNR recognizes the regulatory autonomy of its provincial and territorial members, while remaining committed to the benefits of collaborative dialogue and harmonized approaches to regulation for the protection of the public. Our goal is to provide a forum for provincial and territorial regulators to work together to serve and protect the public interest by advancing excellence in nursing regulation.

As a national organization for the exchange of information regarding regulatory trends, best practices, policy, and legislation, CCRNR participates in national and international discussions to represent and promote an understanding of nursing regulation. We are uniquely positioned to provide the regulatory perspective and to support the public protection mandates of provincial regulators in discussions at the federal level.

I would like to briefly address the term “scope of practice”. Scope of practice is given to a profession in provincial and territorial legislation. Members of the profession work within this scope to the extent of their individual knowledge, skill, and ability. Often the scope of practice of one profession overlaps with the scopes of practice of other professions.

Our regulatory processes are designed to ensure members of the profession are competently working within their defined scope. While there are some differences in the scope of practice for registered nurses across provinces and territories, there are also significant similarities. We share a set of national entry-to-practice competencies, which inform nursing curricula, and a common registration exam reflective of the common requirements for safe nursing practice across Canada.

Scopes of practice evolve with changes in the regulatory and health care environment. Discussions around expanding the scope of practice or authority given to a profession should include consideration of the regulatory mechanisms needed to ensure that public protection is maintained. These include educational requirements, standards to support safe practice, and mechanisms to ensure continuing competence of the profession.

It is also critical that scope of practice discussions take place in collaboration with regulators of other members of the health care team. For example, CCRNR has begun discussions with our colleagues at the Federation of Medical Regulatory Authorities of Canada and the National Association of Pharmacy Regulatory Authorities on common regulatory issues.

I'd like to briefly highlight three examples of CCRNR's work to harmonize regulatory frameworks designed to support the protection of the public in Canada.

CCRNR is a key participant in the creation of the National Nursing Assessment Service, together with our colleagues who regulate practical nurses and psychiatric nurses. With funding support from Human Resources and Skills Development Canada, which is now Employment and Social Development Canada, as well as provincial and territorial governments, the National Nursing Assessment Service will support consistency in the initial assessment of internationally educated nurse applicants and support labour mobility.

CCRNR is also working to harmonize expectations for safe practice by nurse practitioners in response to the federal government's introduction of the new classes of practitioners regulations under the Controlled Drugs and Substances Act. For example, CCRNR has identified criteria for educational courses to be offered across the country to ensure that all nurse practitioners have the necessary competencies to support safe prescribing of controlled substances.

With support from Employment and Social Development Canada, CCRNR is about to embark on a national analysis of nurse practitioner practice in Canada. We will examine the similarities and differences that exist in individual provinces and territories, and we'll use this information to develop consistent approaches for regulating nurse practitioners across the country.

From our work on these foundational initiatives, CCRNR has identified additional opportunities to support consistency in the regulation of nursing's scope of practice. We will be exploring the creation of a national framework for nursing regulation, which we hope will lay the groundwork for a national mobility agreement.

In closing, the Canadian Council of Registered Nurse Regulators is committed to working with stakeholders across the health care system to support the delivery of consistent, safe, ethical health care across settings, geography, and roles. As the federal government continues to explore the question of scopes of practice and other issues regarding nursing in Canada, CCRNR looks forward to extending our collaborative efforts and offering the collective regulatory expertise of our members in future discussions.

Thank you for the invitation to speak with you this morning, and I am pleased to respond to any questions you may have.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

We're now on to the question and answer portion of our meeting. I would just ask the members of Parliament, due to the size of our panel today and the fact that we have a guest via video conference, that we do our best to ask specific questions so that we can keep it concise and we have a good flow of questions and answers.

Ms. Davies, you're first. Go ahead, please.

[Libby Davies, NDP, Vancouver East, BC]

Thank you to all of our presenters for being here today. Hearing you today I feel as though a light bulb has turned on and we're realizing how complex this question is regarding scope of practice and regulation and all the different players involved. I don't know how you manage to navigate the system. Anyway, it's a very interesting subject.

I have two questions.

First, as I understand it from what you've said today, the scope of practice, which falls under provincial or territorial legislation, can differ from province to province, and even where it does differ, there can be conflicts with another profession in that what is actually regulated you may not actually be able to practise. I think I got that from pretty well all of you.

I wonder how we solve that. Is the ideal situation to basically have one scope of practice that's agreed to for RNs, for nurse practitioners, for LPNs, and for psychiatric nurses apply across the country? I'm not quite clear on that. If your answer is yes, I assume then that the role of the federal government is to help facilitate that. Do you see that as a goal, to try to bring some sort of conformity?

For example, I know that in various trades there is what we call the Red Seal program, through which you can get to a level where you can then operate anywhere across the country. I get the sense that we don't have that in the nursing professions. That's one question that maybe Dr. Mildon and Ms. Coghlan could answer.

Second, I was very interested, Dr. Mildon, in your statistic. I think you said that 60% of nurses are in acute care, 15% are in community care, and 10% are in long-term care. There's the whole question of health human resource planning. I imagine the question of shortages varies from place to place, but I still hear stories from nurses who work at the big hospitals in Vancouver, for example, who say that they're continually on call, and they're practically exhausted from stress and overwork. Even in the larger places, there seem to be shortages, so God knows what it's like in small communities where there aren't any resources at all or there are very few.

There is the question of shortages and how we need to make a shift. There is a growing need, for example, in home care, long-term care, and palliative care, and there is more of a shift into community care, but we don't want to do that at the expense of acute care. In terms of the planning for human health resources, where are we falling behind if we want to make sure that doesn't happen?

I realize that's a very big question, but anything you can do to help us sort out what our role should be from a federal perspective would be very helpful. Could you address both of those questions, and if Ms. Coghlan would also like to answer, that would be helpful.

[Dr. Barbara Mildon]

Excellent. Thank you very much for the question.

First, in terms of harmonization of scopes of practice across the country, I will give you a very resounding and enthusiastic yes. We totally believe that would be helpful in several ways. I mentioned the concept of mobility across the country. Several of the presentations today have echoed that. A harmonization of scopes of practice would enable nurses to more easily and more portably travel across the country to provide care where they are needed. That may also indirectly address some of the more geographically based shortages. As well, the notion of responding in an emergency situation would be helped by harmonization of scopes of practice.

It would certainly address the confusion that can appear in our health care system around the scope if we could all basically collaborate on understanding a single scope. I believe if we did that as a group of nursing organizations and providers, we could help our employers understand that scope and not be as concerned about imposing further restrictions, given their unique situations. So on your question with regard to harmonization, my answer is yes.

With regard to the HHR issues, there was some wonderful work done under the auspices of the federal government not that many years ago, the Canadian nursing study, the CNAC study, but also the nursing sector study. Basically I think what happens is that the health care system shifts. The needs of our patients, clients, and residents shift, and some of those predictions that we made didn't come true. The shift to care in the community is actually happening, but what has changed is that it's being provided by different groups of providers. In particular, unregulated providers are a key part of care in the community today as we help seniors age in place.

I suggest that HHR planning is still a somewhat moving target. We are understanding it better, I think, as we go forward. As for what to do to improve the shortages, again, it's a complex mix of employer practices as much as regulatory and association-type support.

[Libby Davies, NDP, Vancouver East, BC]

Could I just interrupt you, as the time here is short.

When you say that the shift is taking place into the community but it's a different group of people and it's unregulated, what does that mean? Are you saying there isn't training or that it's just not part of one of the regulatory systems? Should we be concerned about that?

[Dr. Barbara Mildon]

That's a difficult question to answer. I would invite my colleague, Josette, to respond to that. But from my perspective, it means that the care that's being provided is often support care, supportive care: meal preparation, shopping, laundry, personal care, the care that may not require the direct provision of registered nurse or licensed practical nurse oversight.

Having said that, we know from CIHI, and the statistics are clear, that if we look at home care provided by RNs, in recent years it has deteriorated or decreased considerably as those types of services go forward. But I would not like to leave you with the impression that unregulated providers are not safe. They certainly are in terms of their own scope. Although they are not a regulated profession yet, they may well become in the future.

[The Chair, Conservative, Ben Lobb]

Thank you very much. We're over time.

Mr. Lunney, you have seven minutes, sir.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

I'd like to thank all of you for your presentations.

It's a bit of a disadvantage to us, when you cover so much technical information with numbers and the number of nurses in every category, not to have your presentations in front of us. That simply has to do with the French translation issue. They needed to be here in time for translation so that we could have them in front of us.

That's more for the committee in terms of giving our presenters time to get their presentations in so that they can be translated.

I want to pick up on the question of nurse practitioners. You've all talked about three different categories of nurses that are recognized, RNs, LPNs, and RPNs, and then registered psychiatric nurses in the west. Now we have nurse practitioners. My question has to do with the education process for nurse practitioners and who they are currently regulated by.

Ms. Coghlan, I know you referred to that. I'd ask you to expand a little bit for us on what currently exists and how nurse practitioners are being educated. Where does that take place? Is it a post-BN program, for example? As well, who are they currently regulated by?

[Anne Coghlan]

I'd be happy to assist the committee with that.

Nurse practitioners are registered nurses who have obtained additional education and clinical experience, for the most part at the master's level across Canada, and they are regulated by the regulatory bodies for registered nurses across Canada. In Ontario, the regulatory body regulates registered nurses, registered practical nurses, and nurse practitioners.