public outreach: registered nurse in the extended class ... · submission titled “registered...

Public Outreach: Registered Nurse in the Extended Class: Scope of Practice Review Hamilton Health Sciences and St. Joseph’s Healthcare Hamilton Submission to: Health Professionals Review Advisory Council [email protected]

November 15, 2007 237 Barton St. E. Hamilton, ON L8L 2X2 Telephone: 905-527-0271 ext. 46523 Fax: 905-546-1861 E-mail: [email protected]

HHS & SJHH Submission to HPRAC November 2007 2

INTRODUCTION ......................................................................................................................3

PROPOSED CHANGES TO CONTROLLED ACTS ......................................................4 SETTING OR CASTING A FRACTURE OF A BONE OR A DISLOCATION OF A JOINT ........................4 PRESCRIBING, DISPENSING, SELLING OR COMPOUNDING A DRUG ..............................................5 APPLYING A FORM OF ENERGY PRESCRIBED IN REGULATIONS ..................................................6 COMMUNICATING A DIAGNOSIS ..................................................................................................6 ADMINISTERING A SUBSTANCE BY INJECTION OR INHALATION .................................................7

PUTTING AN INSTRUMENT HAND OR FINGER…………………………………...…………...…………8

MOVING FROM MEDICAL DIRECTIVES AND DELEGATION TO INCORPORATION OF CONTROLLED ACTS WITHIN SCOPE ...........................8

LOOKING TO THE FUTURE.……………………………………….………………. ..9

QUALITY ASSURANCE .......................................................................................................10 CREDENTIALLING….………………………………………………………………………………10 QUALITY ASSURANCE PROGRAM………………………………………………………………11

SUMMARY .................................................................................................................................11

APPENDIX A ……………………………………………………………….…………..12 APPENDIX B ……………………………………………………………………………15


INTRODUCTION

Hamilton Health Sciences (HHS) and St. Joseph’s Healthcare Hamilton (SJHH) are pleased to respond to the Health Professions Regulatory Advisory Council’s (HPRAC) request for written submissions regarding the scope of practice for registered nurses in the extended class.

HHS is a 965-bed, five-site regional tertiary care teaching health sciences center with approximately 10,000 employees and 800 physicians. Members from 16 different professions practise at HHS, each governed by the Regulated Health Professions Act, 1991 (RHPA). SJHH is a 650-bed, three-site regional tertiary health science center with a staff of over 4,000 and 1054 physicians. Members of 17 different regulated professions practise at SJHH. As leading health care providers in our community and the Hamilton Niagara Haldimand Brant Local Health Integrated Network, HHS and SJHH have collaborated to provide this joint submission in response to the HPRAC request for feedback regarding the College of Nurses of Ontario (CNO) submission titled “Registered Nurse in the Extended Class: Scope of Practice Review”. Our commentary overall, is designed to illuminate the impact of the CNO’s proposed changes to controlled acts on the provision of care and administrative decision-making in our acute care, academic teaching hospital settings. Our recommendations have been informed by the ‘limits and conditions’ outlined in the CNO’s proposed standard ‘Performance of Controlled Acts by Nurse Practitioners’ (CNO, Appendix C, p. 31). Our commentary reflects the input of members of professional groups and leadership within our organizations outlined in Appendix A. Letters of support are attached in Appendix B. Structurally, our submission addresses three areas:

1. Proposed changes to controlled acts 2. Moving from medical directives and delegation to incorporation of

controlled acts within scope 3. Quality assurance


PROPOSED CHANGES TO CONTROLLED ACTS Setting or casting a fracture of a bone or a dislocation of a joint Hamilton emergency departments treat patients with simple fractures of the arm, wrist and elbow on a daily basis. A patient presenting to the emergency room with a simple fracture or dislocation may wait several hours in pain before casting or setting is initiated. Once seen by a physician, a patient with a fracture is generally sent to a fracture clinic, where unregulated orthopedic technicians, registered nurses (RNs) in the general class and registered practical nurses (RPNs) are involved in tasks associated with applying casts, removing old ones and reapplying new ones. At HHS, strategies to facilitate access to care for these and other patients in our emergency departments have included the introduction of two advanced practice nurses (formerly known as acute care nurse practitioners). This decision was made in collaboration with the Chief of Emergency Medicine and the respective Chiefs of Nursing Practice. Having graduated from a recognized acute care nurse practitioner program, these nurses had the training and expertise to interpret x-rays, treat simple fractures and the problems associated with these fractures and identify instances where referral to their medical colleagues was necessary and indicated. Unfortunately, these nurses eventually left our departments because they were unable to obtain the necessary physician signatures on the medical directives that would enable them to care for these patients. Some physicians were concerned that should a nurse practitioner make a mistake, the physician would be liable given that they had signed the medical directive. Nurse practitioner access to this controlled act will reduce the time that these patients wait, often in discomfort, to be treated and released from our care and, if required, referrals to physicians will be initiated in a timely and appropriate manner. Supportive changes to regulation 965 under the Public Hospitals Act, 1990 will eliminate the need for medical directives to support NP practice and this will clarify professional accountabilities and facilitate their recruitment and retention in our emergency room departments.


Recommendation HHS and SJHH support CNO’s proposal to permit access to the controlled act ‘setting or casting a fracture of a bone or a dislocation of a joint.’ Prescribing, dispensing, selling or compounding a drug Medications that are frequently required for the patient populations receiving care at HHS and SJHH are not reflected in the current medication list approved by the College of Nurses of Ontario. As a result, numerous additional medications are authorized to NPs through medical directives, with each organization determining the medications that the NP can prescribe. There is no mechanism to ensure consistency among healthcare providers or facilities. We believe that the regulatory body, and not the healthcare facility, should be the organization to make and monitor these decisions. Current CNO approved list-based RN(EC) access to prescriptive authority prohibits NPs from prescribing any off-list medications. Historical delays in updating and revising these lists have resulted in impaired patient access to evolving best practices related to medication treatment and/or delays in treatment until a physician order is received. In an acute care setting, when a NP is attempting to provide care without prescriptive authority, and in the absence of medical directives, care is frequently delayed or compromised. For example, one NP identified a dangerously high potassium level on a cardiac patient that required immediate intervention. This situation can be quickly remedied through administration of a simple oral medication. However, this medication is very specific and is not commonly used and therefore required a physician order. The NP was forced to call the surgeon in the middle of an open-heart operation to obtain a verbal order allowing her to administer the life saving medication. In the absence of a pharmacist, RNs and RPNs require a physician’s order to dispense medications to patients who are granted a leave of absence from the inpatient setting and to patients in some of our outpatient clinics, e.g. Sexual Assault Clinic. With these changes in legislation, a NP would be able to facilitate patients going home for short periods of time without delay when able, and to allow clinics to function effectively.


Recommendation HHS and SJHH support CNO’s proposal to remove the limitations on ‘prescribing’ and to permit access to the controlled act ‘dispensing, selling or compounding a drug.’ Applying a form of energy prescribed in regulations Increasing access of NPs to the ordering of diagnostic testing such as computerized tomography (CT) and ultrasonography in an acute care setting will facilitate earlier and more accurate diagnosis by nursing and medical practitioners and improved patient care. For example, following neurosurgery a patient who develops signs and symptoms of intracranial pressure requires immediate intervention including CT to prevent potentially fatal brain damage. Currently, the NP must consult with the neurosurgeon before ordering and expediting the test to inform urgent decision-making. In acute care, the timely ordering of tests by the NP with advanced training is not a deterrent to, but an essential function of collaboration that results in improved access, the application of evidence-based best practices and improved patient outcomes. Multiple forms of energy including ultrasonography and cardiac pacing are included in the proposed changes. These appropriately reflect current technology and the full scope of the roles performed by NPs with demonstrated expertise in specialty areas. Recommendation HHS and SJHH support the broadening of NP access to the controlled act governing ‘application of energy’ to extend to those forms of energy listed in the CNO proposal. Communicating a diagnosis Establishing, communicating and ordering the tests necessary to make a diagnosis are fundamental components of the NP role in relation to the care and treatment of patients and families at HHS and SJHH. Regulation 965 in the Public Hospital’s Act 1990 impedes the ability of the NP to carry out this critical function. To enable NPs to diagnosis conditions in the patient populations that they serve, a great deal of time and money continues to be invested in developing medical directives. Through this laborious and time-consuming process, each organization is determining the diagnosis that can be made by the NP.


There is no mechanism to ensure consistency between healthcare providers or facilities. Inconsistency frequently results in confusion on the part of vulnerable patients and families in their communication with the inter-professional team that may unnecessarily and inadvertently undermine their confidence in the care provided. The educational requirements outlined in these medical directives are simply that the NP has completed an approved acute care, or primary health care, NP program. As stated earlier, we believe that the regulatory body, and not the healthcare facility, should be the organization to make and monitor these decisions. In regards to consultation with other members of the healthcare team, it is our understanding that this is a basic standard of practice for all RNs, RPNs and NPs. It is unclear why a requirement for consultation needs to be legislated. Removal of these limitations from legislation will facilitate timely, efficient, effective and compassionate care within our organizations. Recommendation HHS and SJHH support CNO’s proposal to remove the limitations on ‘communicating a diagnosis.’ Administering a substance by injection or inhalation The removal of the restrictions for a medical order that is required for NPs to administer or order substances for others to implement by injection or inhalation is required to make the changes regarding prescription previously recommended. This change has been identified as having important implications for the developing role of the NP-Anesthesia. Although the role of NP-Anesthesia does not currently exist at HHS and SJHH, a need has been identified for clarification of the collaborative decision-making processes that will be required in the context of complex surgical procedures and unstable patient populations in an acute care setting. We suggest that this lack of clarity may be resolved in the CNO Standard of Practice for NPs with a clear articulation of the collaborative nature of decision-making in the context of NP-Anesthesia practice.


Recommendation HHS and SJHH support, in principle, the removal of restrictions to the controlled act of ‘administering a substance by injection or inhalation’ for NPs, subject to further clarification regarding collaborative decision-making. Putting an instrument, hand or finger,

i. Beyond the external ear canal, ii. Beyond the point in the nasal passages where they

normally narrow, iii. Beyond the larynx, iv. Beyond the opening of the urethra, v. Beyond the labia majora, vi. Beyond the anal verge, or vii. Into an artificial opening in to the body.

Currently, the Nursing Act (1991) limits NP’s ability to perform these procedures or order them for others to perform without a medical order. The removal of these restrictions is necessary to allow for other proposed changes such as the prescription of substances and other procedures that implicitly require these acts. Recommendation HHS and SJHH support the removal of restrictions for NPs to order and delegate the controlled act of: Putting an instrument, hand or finger,

i. Beyond the external ear canal, ii. Beyond the point in the nasal passages where they normally

narrow, iii. Beyond the larynx, iv. Beyond the opening of the urethra, v. Beyond the labia majora, vi. Beyond the anal verge, or vii. Into an artificial opening in to the body.

MOVING FROM MEDICAL DIRECTIVES AND DELEGATION TO INCORPORATION OF CONTROLLED ACTS WITHIN SCOPE Medical directives and delegation are restrictive, costly and cumbersome mechanisms for regulating the practise of NPs who otherwise have the cognitive and technical skills to perform the


controlled acts under discussion as taught and assessed in current NP programs. New positions and committees have been created within our organizations to address the complicated issues related to meeting regulatory requirements when developing and approving medical directives. It is estimated that each NP medical directive requires between 80 - 100 healthcare hours to develop and approve. This does not include the financial and human resources necessarily allocated to educating other members of the healthcare team or the annual review process. Education of other healthcare team members would be clearer and more consistent if the appropriate controlled acts were authorized to NPs. Regulation of practice is the role of the regulatory body, and we would like to see incorporation of these controlled acts into the scope of practice of the NP. The Canadian Medical Protective Association (CMPA) discourages physician use of medical directives, suggesting that a physician may be found liable if something goes awry with implementation of the directive. As a result, many of our physicians are reluctant to sign a medical directive. This presents a barrier to the recruitment, retention and practice of NPs within our settings. The concerns raised by the CMPA and our physicians are understandable given the blurring of accountability for the performance of a controlled act between the ‘delegator’ and the ‘delegatee’ that exists within the context of a medical directive. The lines of accountability to the public will be clearer if the proposed changes to controlled acts are enacted. This will facilitate the care of our patients. Autonomous practice is the ability to independently carry out the responsibilities of a position. Patient care is frequently delayed because NPs are not authorized to carry out their responsibilities. For example, when a new physician comes on service, the NP must obtain verbal orders until the physician signs the medical directive. Medical directives and delegation inhibit the ability of the NP to practice autonomously. LOOKING TO THE FUTURE: ENGAGING THE NURSING WORKFORCE TO COME In the ‘Report of 2005 Dialogue on Advanced Nursing Practice’ the Canadian Nurses Association identified a number of key messages that were designed to inform health care decision makers as we plan to meet the health care needs of Canadians in the years to come. “Now is


the time to ensure that advanced nursing practice roles are well integrated into the health care system. Both the public and governments recognize that nurses in advanced practice roles can help address priorities in a health care system under severe pressure. Priorities include increasing access to quality health care, reducing waiting times and responding quickly to pandemics and other health emergencies” (p. 3). In this submission to HPRAC we have provided a number of examples that illustrate how the proposed changes to the controlled acts and legislation will improve access to quality health care, reduce waiting times and increase accountability. Added value associated with these changes could also be realized through the retention of nurses in clinical settings once Masters level education is completed. At this time we are only beginning to fully recognize how the baccalaureate entry to practice requirement for RNs in the general class will impact on nursing workforce trends. However, it can be expected that increasing numbers of RNs with undergraduate education will seek out opportunities to complete Masters level education that will provide them with a variety of employment options including remaining in clinical practice, teaching/academia or a career in research. The elimination of regulatory barriers to NP practice through changes proposed by the CNO will provide NPs who remain in clinical practice with a responsive environment that is designed to meet patient needs through the implementation of the full scope of the NP role. This is the type of clinical environment that will help keep Masters prepared nurses at the point of care where they can mentor other nurses and add value by integrating the important non clinical domains of their roles that include research, education and leadership into the care provided. The nursing shortage is a reality that now frames our health human resource planning and should be included in considerations regarding legislation and regulation change. QUALITY ASSURANCE Credentialing The CNO has identified that successful completion of a generic adult, pediatric or primary health care NP examination and completion of an approved academic program are non-exemptible requirements for registration as a NP in Ontario. The proposed ‘Practice Standard: Performance of Controlled Acts by Nurse Practitioners’ limits the performance of the acts further to those with “knowledge and


experience of the specialty for which the Nurse Practitioner holds a specialty certificate” (CNO, Appendix C, p. 31). Employers may be challenged to consistently evaluate the specialty competency of NPs without a list of approved or recommended certifications and approaches to evaluating comparable qualifications or experience. For NPs working in Public Hospitals, consideration should be given to the development of a credentialing process that would be under the authority of Nursing. This would include initial credentialing on hiring and annual renewal of credentials that are consistent with the practice expectations and environments in which the NP is functioning. Such a mechanism would provide protection for the public, the organization and the individual NP. Given that NPs are members of a self-regulatory profession it would not be appropriate for NP credentialing to be under the authority of medicine. However, this in no way diminishes the partnership and collaboration with medicine or other professionals. Quality Assurance Program HHS and SJHH agree with the CNO in that a “well-rounded, rigorous and comprehensive QA program enables CNO to ensure that members maintain competence respecting the new and expanded controlled acts” (CNO, Appendix C, p. 31). Employers would benefit from the CNO developing a framework for credentialing and evaluation that would guide the review of competencies in specialty areas in the absence of a registration requirement for specialty certification. This will assist the employer in recruiting qualified NPs and providing support for the ongoing education and learning needs of existing NPs in a quality practice setting. Ideally, the framework would include formal feedback to evaluate NP inter-professional collaboration. SUMMARY Overall, HHS and SJHH support the changes to legislation and the regulation of NP practice proposed by the CNO. The changes will enhance our capacity to better service the public through increasing timely access to essential healthcare services, ensuring continuity of care and clarifying the accountability of care providers. Opportunities for the CNO to guide employers in supporting NPs, ensuring specialty competency and enhancing inter-professional collaboration and decision-making have been identified.


Appendix A Contributors


Contributors

Kim Alvarado, RN, BScN, PhD: Chief of Nursing Practice Henderson Hospital, Hamilton Health Sciences Karen Antoni, RN, MHSc, ACNP(Diploma). Advanced Practice Nurse, Perioperative Program, Hamilton Health Sciences Winnie Doyle, RN, MN: Vice President Clinical Services and Chief Nursing Executive, St. Joseph’s Healthcare Hamilton Vickie and Steve Chmura: Family of Hamilton Health Sciences patient. Rose-Frances Clause, RN, BScN, MHSc, ACNP(Diploma). Advanced Practice Nurse, McMaster Children’s Hospital, Hamilton Health Sciences. Cheryl Evans, RN, MScN: Nursing Professional Practice Consultant, St. Joseph’s Healthcare Hamilton Dr. Jennifer Everson, BScN, MD, CCFP, FCFP: Vice President Medical, Hamilton Health Sciences Nancy Fram, RN, BScN, MEd: Vice President Professional Affairs and Chief Nursing Executive, Hamilton Health Sciences Heather Hoxby, RN(EC), BScN, MHSc, CHE: Director of Nursing Practice, St. Joseph’s Healthcare Hamilton Sandra Ireland, RN, BScN, MSc, PhD: Chief of Nursing Practice Hamilton General Hospital, Hamilton Health Sciences Barbara L’Ami, RN(EC), BscN: Primary Care Nurse Practitioner, St. Joseph’s Healthcare Hamilton Dr. Moyez Ladhani, MC, FRCPC, FAAP, Deputy Chief, Division of Clinical Paediatrics, McMaster Children’s Hospital, Hamilton Health Sciences Ruth Lee, RN, BScN, MScN, PhD: Chief of Nursing Practice, McMaster University Medical Centre, Hamilton Health Sciences


Charmaine Martin-Gaspar, RN, BScN, MSc(T), ACNP(Diploma): Advanced Practice Nurse Neurosciences and Trauma Program, Hamilton Health Sciences Kelly O’Halloran, RN, BScN, MScN, ACNP(Diploma): Advanced Practice Nurse, Cardiac and Vascular Program, Hamilton Health Sciences. Jan Park Dorsay, RN, BAA(N), MN, ACNP(Diploma). Advanced Practice Nurse, Rehabilitation Program, Hamilton Health Sciences Arlene Sardo, RN, BS/MS, ACNP(Diploma): Advanced Practice Nurse, Orthopaedic Program, Hamilton Health Sciences Dr. Peter Steer, MB, BS, FRACP, FRCPC, FAAP: President, McMaster Children’s Hospital, Chief and Chair, Department of Paediatrics, Hamilton Health Sciences. Irene Travale, RN, BScN, MSc, ACNP(Diploma): Advanced Practice Nurse, Cardiac and Vascular Program, Hamilton Health Sciences. Jennifer Wiernikowski, RN, BScN, MN, ACNP(Diploma): Chief of Nursing Practice Juravinski Cancer Centre, Hamilton Health Sciences


Appendix B Letters of Support


November 14, 2007 Barbara Sullivan Chair, Health Professions Regulatory Advisory Council 55 St. Clair Avenue West, Suite 806 Toronto, ON M4V 2Y7 Re: Request for Submissions Regarding the Scope of Practice for Registered Nurses in the Extended Class Dear Ms. Sullivan: As Vice President of Clinical Services and Chief Nursing Executive of St. Joseph’s Healthcare Hamilton, I am pleased to support the changes to legislation proposed by the College of Nurses of Ontario. These changes will establish a regulatory and legislative framework that will enable the four streams of Nurse Practitioner (NP) practice to be safely, fully, and effectively integrated into the health care system. If enacted, these changes will remove existing longstanding barriers to NP practice, support their full utilization across all settings, and facilitate timely public access to high quality, safe, and appropriate health care services. Our written submission provides additional commentary on the specific changes from our perspective as a premier academic health sciences centre. We look forward to the removal of regulatory barriers that require complex and costly authorizing processes and result in unclear accountabilities. The proposed changes will enhance patient care and serve the public interest, and are consistent with self-regulation and the principles of the Regulated Health Professions Act. Thank you for this opportunity to contribute to your decision-making process. Sincerely,

Winnie Doyle, RN, BScN, MN Chief Nursing Executive and Vice President Clinical Services St. Joseph’s Healthcare Hamilton

Professional Affairs 237 Barton Street East

Hamilton, Ontario L8L 2X2 (905) 527-0271 (46527)

Fax (905) 546-1861

November 14, 2007 Ms. Barbara Sullivan Chair, Health Professions Regulatory Advisory Council 55 St. Clair Avenue West, Suite 806 Toronto, ON M4V 2Y7 Re: Request for Submissions Regarding the Scope of Practice for Registered Nurses in the Extended Class Dear Ms. Sullivan: As Vice President of Professional Affairs and Chief Nursing Executive of Hamilton Health Sciences, I am pleased to support the changes to legislation proposed by the College of Nurses of Ontario. These changes will enable Registered Nurses in the Extended Class to perform controlled acts that have become an expected, essential part of their practice and that contribute to increased access to, and timeliness of care. Our written submission provides additional commentary on the specific changes from our perspective as a tertiary academic health science center. Hamilton Health Sciences has had a positive experience with Advanced Practice Nurses (formerly Acute Care Nurse Practitioners) and Primary Health Care Nurse Practitioners that spans twenty years. In fact HHS was one of the first hospitals in Canada to support the introduction of the APN role in the Neonatal Intensive Care environment. Our experience is consistent with the published peer-reviewed evidence supporting these roles.

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We look forward to the removal of regulatory barriers that require complex and costly authorizing processes for this category of nurses and at times delays patient access to care. Thank you for providing us with an opportunity to contribute to your decision-making process. Sincerely yours,

Nancy Fram, RN, BScN, MEd Vice President of Professional Affairs and Chief Nursing Executive Hamilton Health Sciences

Dr. Jennifer L. Everson, BScN, MD, CCFP,FCFP Vice President, Medical

McMaster Site Telephone: 905 521-2100 Room 2E37 Ext. 42030 1200 Main Street West Fax: 905 521-5076 Hamilton, ON L8N 3Z5 [email protected] _________________________________________________________________________ November 15, 2007 RE: HPRAC Submission To Whom It May Concern: As Vice President Medical at Hamilton Health Sciences, I have had the opportunity to discuss the HPRAC submission with our Chiefs of Anaesthesia, Surgery, Medicine, Paediatrics and the Emergency Department. They are all supportive of the initiative to increase the scope of practice of these highly qualified practitioners. It was also a pleasure to be part of the presentation in Hamilton on Thursday, November 8, 2007. If you require further information or assistance, please do not hesitate to contact my office. Yours sincerely HAMILTON HEALTH SCIENCES

Jennifer L. Everson, BScN, MD, CCFP, FCFP V.P. Medical JE/jmy

November 2, 2007 To: Health Professions Regulatory Advisory Council (HPRAC)

RE: College of Nurses of Ontario (CNO) Submission, August 2007: Registered Nurse in the Extended Class: Scope of Practice Review

I am writing to you as the President of McMaster Children’s Hospital, Chief of the Department of Pediatrics, and a Neonatologist.. We have worked with Advanced Practice Nurses (formally Acute Care Nurse Practitioners) as a part of our inter-professional teams for over two decades. As a result, we can say with confidence that our experience has been an extremely positive one in the way in which their care has enabled increased continuity though the continuum of care, provided timely services and promoted patient safety. There is publicized peer reviewed evidence of the effectiveness of this practice. They have demonstrated their contribution to enhancing the quality of life for the patient and family as well as to minimize inefficiencies to our health care system.

We are in full support of CNO’s proposal to broaden the NP scope of practice, including the addition of several controlled acts and the removal of restrictions applied to current acts. We understand that to support full utilization of the specialty NP role, certain regulations must be revised, including Regulation 965 of the Public Hospitals Act, 1991. This would provide the authority to the NPs to treat inpatients thereby removing the need for restrictive and cumbersome medical directives that require onerous approval processes. This not only enables the NP to focus energy on providing more timely access to health care for patients, it clarifies and ensures direct accountability for practice.

Sincerely,

Peter Steer, MB, BS, FRACP, FRCPC, FAAP President, McMaster Children’s Hospital Chief and Chair, Department of Pediatrics Executive Lead, MUMC Site

cc: Dr. Jennifer Everson

Department of 1200 Main Street West Phone 905.521.2100 Pediatrics Hamilton, Ontario Fax 905.521.4981 L8S 4J9

C H E D O K E • C H I L D R E N ’ S • G E N E R A L • H E N D E R S O N • M c M A S T E R

November 2, 2007 To: Health Professions Regulatory Advisory Council (HPRAC) RE: College of Nurses of Ontario (CNO) Submission, August 2007: Registered Nurse in the Extended Class: Scope of Practice Review I am writing to you on behalf myself, and Dr. Madan Roy, as Deputy Chief and Chief, Division of General Paediatrics/Director, Neonatal Nurseries, respectively, at McMaster Children’s Hospital. We understand that you have been asked by the Minister to review the scope of practice for registered nurses in the extended class, namely Nurse Practitioners (NP). We have worked with Acute Care Nurse Practitioners as a part of our inter-professional teams in the settings of Neonatal Intensive Care, General Pediatric Inpatient Units, as well as Pediatric Outpatient Clinics. As a result, we can say with confidence that our experience has been an extremely positive one in the way in which their care has enabled increased continuity though the continuum of care and promoted patient safety. They have worked with some of our most medically complex and technology-dependent infants and children, a population whose care demands consistency and coordination of services so as to maximize quality of life for the family as well as to minimize inefficiencies to our health care system. We are in full support of CNO’s proposal to broaden the NP scope of practice, including the addition of several controlled acts and the removal of restrictions applied to current acts. We understand that to support full utilization of the specialty NP role, certain regulations must be revised, including Regulation 965 of the Public Hospitals Act, 1991. This would provide the authority to the NPs to treat inpatients thereby removing the need for restrictive and cumbersome medical directives that require onerous approval processes. This not only enables the NP to focus energy on providing more timely access to health care for patients, it clarifies and ensures direct accountability for practice. McMaster Children’s Hospital vision is to advance health and integrate care for children and youth through excellence, innovation and partnerships. We believe that part of this excellence is to offer advanced nursing care through the use of nurse practitioners, as envisioned by CNO’s proposed scope of practice. Thank you for the opportunity to allow us to voice our support of this most important health professional issue. Sincerely,

Dr. Moyez Ladhani, MC, FRCPC, FAAP Deputy Chief, Division of General Paediatrics McMaster Children’s Hospital, Program Director, Paediatric Postgraduate Medical Education Associate Professor, Paediatrics McMaster University

Transcribed from November 8, 2008 HPRAC Forum Presentation: Rose-Frances Clause, RN, BScN, MHSc, ACNP(Diploma). Advanced Practice Nurse, McMaster Children’s Hospital, Hamilton Health Sciences Good evening. My name is Rose-Frances Clause and I am an Advanced Practice Nurse at Hamilton Health Sciences working with a unique population of children who require much technology to sustain life at home. I am grateful to be here this evening for the opportunity to share with you how the proposed changes to the legislation governing the practice of Nurse Practitioners in Ontario will enhance my role and ultimately improve access to patient care. My role this evening, is to share with you my story of caring for the families that I have been entrusted with through McMaster Children’s Hospital at Hamilton Health Sciences. It is an honour and a privilege to work with some of our most medically fragile children, namely those who require such support as tracheostomy tubes and home mechanical ventilation, as well as those requiring home parenteral nutrition. I work with an incredibly dedicated inter-professional team made up of numerous allied health professionals, physicians and community care access case managers. History of Role I began my journey as an Advanced Practice Nurse 13 years ago, with the mandate to enhance the care delivered to this most special population of children. Due to the nature of the conditions that these patients are faced with, they require ongoing access to the continuum of care from hospital to home, specialty out-patient clinics and readmissions to hospital for acute on chronic episodes. The focus of improved patient care therefore lies in the ability to: listen to our families’ needs; liaise with the numerous providers from the hospital and community settings; coordinate services and provide timely access to safe patient care. Current Role My role began as a Clinical Nurse Specialist and then evolved into the role of Acute Care Nurse Practitioner as it became increasingly apparent that such specialized care required a dedicated practitioner consistently monitoring the medical issues and numerous details of care. My involvement with these families begins as in-patients with continuation of care for as long as they need the technology or are transferred to adult services. Once identified that an infant or child will require such technology long-term, I am enlisted to help prepare the families for discharge, including education relating to medical equipment, feeding and medication administration, emergency care and ensuring that all details are in place for a safe discharge. I then remain as the main contact at the hospital for ongoing issues along with either the home ventilator team of respiratory therapist, respirologist and pediatrician or the home parenteral team of pediatric gastroenterologist and registered dietician. I see the patients on home visits as well as in the out-patient clinic, providing not only specialty care related to their condition and associated

technology, but provide their primary care as well. I provide telephone support to the community nurses and other allied health caring for these children at home. Once readmitted, I continue to provide support to the in-patient team managing their care, and then support their journey back home once again. The Issue Enabling the four streams of specialty practice for nurse practitioners as well as removing barriers in existing legislation has huge implications for my practice. This will allow me the flexibility to fully enact my scope of practice across the settings from in-patient to outpatient, thereby decreasing inefficiencies of system issues and increasing timely access to care. A Case Story The families that I serve work extremely hard to maintain a state of wellness for their children, learning all aspects of their children’s care. This means learning how to manage a child on a ventilator, suctioning a tracheostomy tube, using feeding pumps, performing sterile technique to access a central venous access line. They do everything in their power to avoid readmission to hospital and are so in tune with their children’s health, can often diagnose that an acute illness is brewing before we can detect it on examination. Timely access to treatment is therefore paramount in averting readmission to hospital. Let me walk you through a typical example of the kinds of issues my families face. Their child is on a ventilator 24 hours/day. The mother notices over the past several days that the child is just not herself. The mother calls me to discuss her findings and her gut feeling that her daughter is brewing something. We discuss the issues and if we both believe that the child is well enough to remain at home, but not quite sick enough to begin treatment, the mom takes a respiratory sample for culture and drops it off to the lab. I inform the physician of the circumstances and I monitor for culture results. Once results are in, I am the first one to access these results and interpret the fact that the child indeed requires antibiotics. Currently as an in-patient advanced practice nurse, I do not have prescriptive authority for out-patient pharmacies. I must then spend valuable time locating the physician, discussing results, getting a prescription and faxing this prescription. If the physician is not available, the patient is left waiting until I can complete the process with the physician’s assistance, wasting valuable time in accessing treatment. If open prescriptive authority could be approved, even if the physician is not available should I require consultation for deciding treatment, I can access an Infectious Disease Specialist to make recommendations for care that I can then carry out. Now envision another child, one at home on I.V. nutrition 14 hours/day. This child has spiked a fever and must now come to hospital to be admitted for blood cultures and I.V. antibiotic therapy. Unfortunately, the child is being admitted under the physician whom has just begun working at our hospital and has not yet been added to my medical directives, the legislation that currently enables me to treat in-patients. Therefore, I cannot write orders on the patient whom I know best and can help to facilitate seamless care from home to hospital. Again, valuable human resources are being wasted as I am

forced to spend time accessing support for care that I have already been educated in to provide, and hired within a role whose purpose is to improve continuity in the provision of safe and timely access to care. Making the proposed changes to various regulations, including 965 of the Public Hospital Act, would remove the need for cumbersome medical directives and allow a role such as mine to practice to its fullest potential and intended scope. The crux of my role is to provide continuity of care to families whose lives have been devastated through the diagnosis of a life threatening chronic illness that requires much technology in the home to simply survive. I know that I must take full accountability for my actions and do not take lightly the knowledge, skills and judgment necessary to manage such medically complex children. By removing barriers and adjusting legislations, autonomous authority can then ensure direct accountability, thus enabling me to work within the inter-professional team with increased clarity and efficiency. Key Points So in conclusion, I would like to summarize a few key points for your consideration:

• As a group of experienced advanced practice nurses, we have proven our ability to provide safe in-patient care that is in keeping with published peer reviewed literature, removing access barriers and thereby enabling a more efficient health care system.

• The current legislation governing nurse practitioners promotes an inefficient use of well-educated human resources.

• Improved legislation, as recommended, will align us with the already established specialized NP practices of other Canadian jurisdictions and such countries as the US and the UK.

• Realizing the full scope of the nurse practitioner role will not only improve job satisfaction and ensure retention, it will promote the continued education and grooming of our next generation of nurses to come.

On behalf of the families and professionals with whom I work, and my colleagues in advanced nursing practice, I thank you in advance for considering the recommendations put forth by the College of Nurses to broaden the scope of practice and support full utilization of the Registered Nurse, Extended Class, Specialty Nurse Practitioners. Thank You.

public outreach: registered nurse in the extended class ... · submission titled “registered...

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