Ontario Medical Association

ONTARIO MEDICAL ASSOCIATION

Submission to the Health Professions Regulatory

Advisory Council

Respecting

Scope of Practice for

Registered Nurses in the Extended Class

October 2007

Ontario Medical Association

Suite 200, 525 University Avenue

Toronto, ON M5G 2K7

Telephone: 426/599-2580 or 1-800-268-7215

INTRODUCTION

The Ontario Medical Association (OMA) is the professional association for the physicians of Ontario and we have been active and positive contributors to discussions about how best to regulate health care providers since the development of the Regulated Health Professions Act (RHPA) and its companion acts.

We welcome Minister Smitherman's referral of issues relating to the scope of practice for Registered Nurses – Extended Class (RN(EC)s) to the Health Professions Regulatory Advisory Council (HPRAC) and, indeed, called for such a referral last year. We welcome the objectivity that can be brought by an independent, expert body and appreciate the opportunity to participate in HPRAC's review.

PURPOSE OF PROPOSED CHANGES

In its August 24, 2007 submission to HPRAC, the College of Nurses of Ontario (CNO) states (page 13) that the proposed changes are intended to achieve a number of aims, including enabling RN(EC)s to provide health care services to hospitalized in-patients. We note, however, that the body of the submission does not seem to deal with the implications of such a change. There have been numerous Coroner's Inquests over the years dealing with issues around designation of a Most Responsible Physician for patient safety. In our highly stressed system, most hospital in-patients today are very sick, often with multiple co-morbidities. We must take care to ensure that whatever changes we make in the system do not inadvertently result in detriments to patient care.

PROPOSED CHANGES TO CONTROLLED ACTS

The new controlled acts are:

-setting or casting a fracture of a bone or a dislocation of a joint;

-dispensing, selling or compounding a drug; and

-applying a form of energy prescribed in regulation.

Joints and bones – The OMA agrees that specially trained NPs can be utilized for the reduction of dislocated joints in circumstances where there is a threat to nerves, soft tissues, or cartilage and the reduction can be completed safely without sedation. The OMA believes, however, that the regulations should require that the patient be referred to an appropriately trained physician for review following the reduction.

The reduction of fractures and maintenance of the reduction is clinically challenging, even for physicians with training and expertise in the area. Determining severity and whether or not a surgical intervention is required is difficult. In addition, the ability to interpret x-rays is critical to the successful setting and casting of fractures.

It appears that nurses intend to limit the types of fractures they will treat, only doing the "easy" ones (ie. wrists and ankles), however, all anatomic sites have fractures that are problematic and some variations that should not have a closed reduction. Knowing the difference is critical.

The OMA does not believe that NPs have the training and related skills required for setting or casting of a fracture.

As a final note, the OMA queries the CNO's explanation that being able to undertake orthopaedics in the emergency department is related in any way to the proposition that expanding NPs' scope of practice will facilitate care of those with "chronic illness" (page 22 and 23).

Prescribing, dispensing, selling and compounding drugs – The CNO proposes to remove all regulatory restrictions that have been placed upon nurses who prescribe.

There have been several examples of drugs put forward for inclusion on drug lists that the OMA has pointed out to be incorrect for the purpose indicated. In response, we learned that the CNO puts forward any drug that is submitted by a practitioner, without vetting them. Should this process be removed from public review, there would be no oversight to prevent such errors in the future. The OMA accepts that the current review system is cumbersome. We are less willing to accept that administrative convenience should be the driving factor for change. We suggest that HPRAC consider options which are more manageable that still protect the public interest. We also note that a more flexible process was introduced in the recently passed Health System Improvements Act and suggest that we implement and evaluate it before abandoning the process of stakeholder review entirely.

The CNO states that allowing NPs to prescribe without restriction facilitates their ability to work to their full scope of practice. The issue of working to one's full scope is an interesting notion and it has important implications in the primary care setting, where the training and scope of the MD exceed that of the NP, yet nursing emphasizes its need to make direct referrals to physician consultants. By-passing the GP/FP means that he/she is not working to full scope and the nurse misses out on an important and accessible source of advice.

As HPRAC considers the advisability of NPs dispensing, selling and compounding, it may wish to review the approach taken by the College of Physicians and Surgeons of Ontario (CPSO). A physician may only dispense, sell or compound a drug where the services of a pharmacist are not reasonably readily available (Medicine Act, 1991, O. Reg 114/94 as amended to O. Reg 122/03). Patient safety is enhanced by the involvement of a professional that is specially trained in pharmacology to dispense medications (ie. a regulated pharmacist). The CNO’s request appears to isolate nursing practice from both medicine and pharmacy, rather than promoting interprofessional care.

Communicating a diagnosis – The CNO proposes to remove the current requirement that members comply with prescribed standards of practice respecting consultation with members of other health professions. It is not apparent to the OMA how this requirement is an impediment to nursing in the extended class. Nurses with advanced training in a particular area will still have less expertise than physicians in the equivalent specialty field (and in this instance “specialty field” is intended to include FPs and RN(EC)s in primary care). It is, therefore, useful to acknowledge this fact and clearly articulate a requirement for consultation. The OMA once again notes that the CNO proposals appear to remove nursing away from collaboration in care.

Administering a substance by injection or inhalation– The CNO proposes to remove the current limitations, thereby facilitating expansion of nursing roles in the delivery of anesthesia.

The OMA supports appropriate regulatory changes to enable NPs-Anesthesia to work as part of an Anesthesia Care Team (ACT), as defined by the government and the OMA in their April 2006 report entitled, "Transforming the Delivery of Operative Anesthesia Services in Ontario". The document states that "The ACT consists of anesthesiologists and specially trained other health professionals, RNs and RRTs, working under the supervision of anesthesiologists for a specified set of anesthesia services." The notion of team supervision by an anesthesiologist is a critical feature of the model which is now being pilot-tested in a number of sites across the province.

The OMA believes that the controlled acts for NPs – Anesthesia should be limited by a statement indicating that all such acts are undertaken consistent with an anesthesia care plan that has been developed in consultation with an anesthesiologist. In recognition of the need for NPs – Anesthesia to act quickly in a rescue situation, we suggest a statement indicating that an NP – Anesthesia may initiate life-saving ACLS algorithms while waiting for a physician response.

The OMA asks HPRAC to carefully consider its recommendations with respect to anesthesia care. This is an area of considerable stress in the system and decisions taken as a result of this consultation could have a profound impact upon the system if handled indelicately.

Applying forms of energy – We note inconsistency between the text on page 15, in which the CNO states that NPs would not operate a high-frequency diagnostic ultrasound machine or perform diagnostic ultrasonography (page 15), and Table 3 (page 14), where theCNO requests the ability to both order and apply soundwaves for diagnostic ultrasound. The OMA does not support the request of nursing to apply diagnostic ultrasound.

The CNO seeks to both order and apply transcutaneous cardiac pacing. This is a rescue technique and should be performed only following consultation with a physician. In a team setting, the most effective and appropriate rescue technique is the immediate availability of the supervising anesthesiologist or other appropriately trained physician. Again, the OMA supports the ability of NPs – Anaesthesia to initiate life-saving ACLS algorithms while waiting for a physician response.

The CNO requests that nurses be granted the authority to order MRIs. The OMA notes that there are emerging questions about the impact of MRI upon patients, particularly in light of the fact that less trained providers tend to order more tests. Further, in light of current resource limitations, most hospitals require approval of MRI tests by a trained medical specialist. The OMA believes that NPs should be able to order MRIs only with an appropriate physician consultation.

The OMA notes that forms of energy would include lasers. This is an area that is clinically very broad – and includes risky cosmetic procedures as well as specialized procedures like colposcopy. The OMA recommends that HPRAC place appropriate limitations upon this controlled act.

MOVING FROM DELEGATION TO INCORPORATION OF CONTROLLED ACTS WITHIN SCOPE

The CNO repeatedly states in its submission that it is necessary, as a part of true self-regulation, to move from the use of delegation towards subsuming the acts into the profession receiving them. There is merit to this argument, however, the CNO seems to miss a fundamental point, which is that there are two parts to the delegation process: the first is the cognitive appraisalabout the nature of the task and the second is the technical execution. Delegation assumes that the cognitive appraisal is done by the delegator and does not require the receiver to have the skills to independently assess the situation; rather, it uses carefully crafted algorithms to help the receiving provider determine which set of activities to undertake. It is incorrect, therefore, to assume that merely because a technical act is executed many times that the person doing it has the judgment required to independently determine the best course of action.

The CNO states that moving away from delegation and towards incorporation of additional controlled acts will create clearer lines of accountability. The OMA agrees that in some instances this will be the case, however, in other circumstances it will introduce greater medico-legal complexity. This argument is over-stated.

The CNO states that there is no direct supervisory relationship between nurses and the providers who delegate controlled acts. They then go on to acknowledge, however, that the CPSO uses the term "supervision" in its policy. The CNO seems to be confusing the act with the actors. While the physician (delegator) supervises the act and has medical-legal responsibility for the act, he/she does not generally have a line supervisory role over the provider who undertakes the delegated action. At the end of the day, however, there is no doubt that the physician (delegator) supervises the care. To suggest otherwise is misleading.

COLLABORATION

The OMA has commented in several places in this submission that the CNO proposals seem to seek to distance nursing from collaborative care. We note that the CNO makes reference to public polling results that support NPs (page 23), however, as physicians we would tend to emphasize that these findings really only say that they want NPs to work with physicians. We have seen no evidence that the public is comfortable with an independent model of advanced-care nursing.

There seem to be two inconsistent directions emerging in health-care. Groups like the NPs are seeking increasingly autonomous and independent practice, while at the same time the government is promoting increased team work. We ask HPRAC to actively consider this dilemma and to make explicit recommendations to the Minister as to how to make collaboration real.

COSTS

The HPRAC framework called upon the CNO to comment upon the anticipated cost/benefit implications for its proposed changes, however, no cost projections are included in the submission. Are they provided under separate cover and, if so, are they available for stakeholder review?

MISCELLANEOUS

The government accepted a previous CNO recommendation requesting protection for the title "Nurse Practitioner" as part of the Health System Improvements Act. The OMA supports this as an important step towards greater clarity and transparency in nursing. At present, there are dozens of nursing "titles" used with virtually no consistency or shared meaning. In addition to efforts to ensure that only nurses who meet CNO criteria can use the title "NP", the OMA suggests that HPRAC recommend to the government and the CNO that all titles which connote a professional designation except for RN, NP and RPN be eliminated from usage (e.g. ‘advanced care nurse’, ‘clinical nurse specialist’, etc.).

The OMA notes that it is becoming increasingly difficult to distinguish one profession from another by relying on the "controlled acts" model. The training and philosophy that supports nursing practice is fundamentally different from medical practice. These differences were once translated into practice through scopes of practice and controlled acts. Increasingly, however, by focusing upon technical competencies, we have lost sight of a significant difference in medical and nursing practices – the time and the training geared towards decision-making. It is one thing to build a nurse’s skills in a particular area, but quite another to equate them with a broad-based medical education.

The OMA asks HPRAC to take a step back and review where the reasonable line exists between professions based upon their training and competencies. It is unclear how we can continue to justify the longer and more rigorous training undertaken by physicians if their services are to be legally and clinically equated to professionals with considerably less training. Some seem to suggest that the answer is to allow lesser-trained professionals to do the less complicated work and to leave the more difficult cases for physicians. This makes sense, to a degree, however, everyone needs balance in their work day and most people prefer variety. We must be careful not to erode interest in medicine by making it unduly difficult and unattractive.

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OMA Submission to HPRAC

Scope of Practice for RN(EC)s