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.