Health Committee on April 8th, 2014

[Dr. Barbara Mildon]

I'll be very brief.

For long-term care settings, nurses should be able to manage care in place. The Ontario government recently announced funding for nurse practitioners in long-term care settings. That means that your mother may not have had to go to the hospital in the first place. She may have been able to be cared for in that setting.

First of all, it's to maximize scope of practice so we can care for in place. Second, with regard to turf, I don't think it's turf; I think it's confusion. I think there is legitimate confusion, particularly in the area of overlap. I will particularly state the RN and LPN roles. The clarification needs to be constant. It needs to be case-based or patient-based.

Those would be my suggestions.

[The Chair, Conservative, Ben Lobb]

Okay. Thanks very much.

We almost could get this meeting done today because everybody who we need to be in the discussion is here today. Maybe we'd better just lock the door.

Next up is Mr. Gravelle.

Go ahead, sir, for five minutes.

[Claude Gravelle, NDP, Nickel Belt, ON]

Thank you to the witnesses for being here.

I probably heard every single one of you talk about the scopes of practice.

Is there an inventory of the best scopes of practice in the provinces or in Canada for hospitals? If there is not an inventory of these scopes of practice, what's preventing it from happening? What do we have to do to make this happen?

I'm directing this question to anybody.

[Dr. Barbara Mildon]

I would invite Anne to speak to this. I'm happy to as well.

Anne, would you like to start?

[Anne Coghlan]

Yes. Thank you.

First of all, I believe that the provincial and territorial nurse advisers have recently conducted a project to collect the different scopes of practice that exist in provinces and territories across Canada. That compilation, if you will, has been done.

I think, though, that we need to go back to that term. Scope of practice is a very broad term. I would argue that there are more similarities across Canada than there are differences in the actual articulation of scope of practice. Where there are differences is in the enactment of the scope, that is, what it looks like in terms of individual nursing practice, how employers interpret this scope, and how it's regulated.

In my earlier remarks I commented on the work that we're doing to harmonize the regulation of this scope of practice. I don't think it's so much an issue of looking at the differences in how it's articulated; I think it's more an issue of the enactment of those scopes of practice.

[Dr. Barbara Mildon]

I believe Paul can also respond from the practical nurse regulator perspective.

[Paul Fisher]

Underutilization of practical nurse scope of practice is a key issue in that regard.

I think that when we're looking at how care is delivered, we also need to include members of the general public in regard to the consultation process, which sometimes we fail to do.

[Dr. Barbara Mildon]

I would add very quickly that, as both my colleagues have alluded to, wouldn't it be wonderful if we had a single definition of scope of practice and standards of practice across the country? I think that's the aim of what we need to do.

[Claude Gravelle, NDP, Nickel Belt, ON]

Is it preventing us from having a single definition?

[Dr. Barbara Mildon]

That's a loaded question.

[Claude Gravelle, NDP, Nickel Belt, ON]

It's a loaded panel.

[Dr. Barbara Mildon]

Again, we need to look at where the jurisdictional authority for health is vested within the jurisdictions. I think that in itself creates the first barrier. But I think the work you're doing as a committee is trying to break down that barrier. I think with your deliberations and your recommendations we're getting closer to that. With the work that my colleagues have spoken to, it's their work to lead harmonization across the country.

[Claude Gravelle, NDP, Nickel Belt, ON]

Thank you.

How much more time do I have?

[The Chair, Conservative, Ben Lobb]

You still have a minute and thirty seconds to solve all the problems here.

[Claude Gravelle, NDP, Nickel Belt, ON]

I read in a report, I believe it was from Manitoba, that there's this Toyota management system where an employee can stop the production line and fix the problem. In hospitals it means an internal hotline where the first-line employees, nurses, can stop and try to fix a problem. This is being done in New Zealand where there's been a 35% increase in efficiency. In the United States the Virginia Mason Hospital & Medical Center in Seattle started that program in 2002 and it's considered one of the levers.

Is this happening in Canada with nurses? If it's not, why not?

[Dr. Barbara Mildon]

I'm happy to say that it absolutely is happening in Canada. It has several names. I think you're referring to the lean methodology, which is well known in hospitals and in health care settings.

There's also a program related to that called Releasing Time to Care. We've had wonderful projects taking place across the country. Vancouver Coastal Health Authority is well known and had one in more recent years. The basic premise is twofold: number one, to maximize patient safety, because it is about patient safety; and number two, it's about having time to care, about having the nurses or our colleagues at the bedside or on the home side, wherever they may be, with patients.

This is well known. It is happening. Again, as with most things, you won't find a consistent implementation of it. You'll find pockets of it across the country.

[Claude Gravelle, NDP, Nickel Belt, ON]

What's preventing us from being consistent throughout the country?

[Dr. Barbara Mildon]

I would point quickly to the work of the Council of the Federation and their health innovation working group. This is in fact what they're trying to do: to bring these best practices forward. Most recently, they have adopted a couple of models of best practice related to diabetes foot care, for example, and so forth, so it is happening. It's just not the tidal wave that I think you as a committee are looking for.

[The Chair, Conservative, Ben Lobb]

Thank you very much, Mr. Gravelle.

Mr. Wilks, please, for five minutes.

[David Wilks, Conservative, Kootenay—Columbia, BC]

Thanks to the witnesses for being here today.

Dr. Mildon, in your presentation you touched on the modification of section 14, I believe it was, of the FDA, the Food and Drugs Act, with regard to the administration of sample drugs by registered nurses and nurse practitioners, I believe. We just went through a study on prescription drug abuse that identified a lot of flaws in the system, shall we say. I want to get your read on that, and probably that of Mr. Fisher as well. With regard to the sample drugs that are handed out by the big pharmacare people, it's normally an aggressive marketing process that they go through. They're providing a new drug into the market on a sample basis, and sometimes, if not all the time, the risks are higher than with the known drugs.

I'm curious to know, from the perspective of the registered nurses and nurse practitioners, if they're given the authority to hand out a sample drug, what information they would provide with regard to that sample drug. If they believe the sample drug is not applicable to that patient, would they refuse to provide it?

[Dr. Barbara Mildon]

Again, my regulatory colleagues may wish to respond, but very quickly I'll say that this is why we have regulated health professionals. They are under the obligation to practise in a safe, evidence-based way, so I can pretty safely guarantee that no registered nurse would give a patient a sample of a drug that they do not need and for which they've not provided that patient with information about what the drug does, why they need to take it, and how they need to take it.

The drugs that they would give out are drugs that the patient would see.... For example, I'll go back to blood pressure. There's a host of blood pressure medications on the market. All of them have various side effects. Some of them are more effective than others with particular patients. Sometimes you have to try two, three or four blood pressure medications until you get the effect of reducing and controlling that patient's blood pressure. That is why giving out samples is so helpful.

But from a safety perspective, I have no hesitation in saying that you wouldn't find a nurse giving a sample inappropriately.

[David Wilks, Conservative, Kootenay—Columbia, BC]

Does that also include, from the perspective of the nurses...if there are potential adverse reactions to those drugs, would you let the patient know that as well?

[Dr. Barbara Mildon]

Most definitely. That is a key part of giving education about drugs and we're mandated to do that.

[David Wilks, Conservative, Kootenay—Columbia, BC]

Thank you.

Is there anyone else on the panel who would like to speak to that? If not, I'll carry on to my next question. Thank you very much.

I'm going to change my role here. From the perspective of nursing in Corrections Canada, there are challenges between the federal system and the provincial system in that, as you know, those who are in the federal penitentiaries are serving much longer sentences and sometimes—well, all the time—for more serious crimes. Is there a difference or are there challenges in the nursing profession with respect to the federal penitentiary system compared to the provincial jail system? Are there different challenges? Or are there opportunities for which we could equal the scope of practice to allow better movement between those two systems?

I don't know who could answer that. I'm sorry. There are too many knowledgeable people here.

Anne, I saw you put your hand up. Thanks.

[Anne Coghlan]

I'm happy to start.

I would say that the standards are the same, and the expectation for nurses, regardless of what setting they're working in, is the same.

I think some of the challenges in the facilities you're talking about relate to a blurring of roles and an understanding within the setting of the role of a nurse as opposed to the role of a correctional officer. There are times when nurses are put in positions where their ability to practise according to the standards of the profession is not well understood and may be compromised because of the way settings are staffed and the policies and requirements in those facilities.