«Practice For Registered Nurses IMPORTANT NOTICES REGARDING THIS DOCUMENT June 10, 2016 CRNBC has put into effect standards, limits and conditions for ...»
Protecting the public by
Scope of effectively regulating registered
nurses and nurse practitioners
For Registered Nurses
IMPORTANT NOTICES REGARDING THIS DOCUMENT
June 10, 2016
CRNBC has put into effect standards, limits and conditions for RNs
assisting in the provision of Medical Assistance in Dying. These
standards, limits and conditions are currently in a standalone
document, which can be accessed here:
Standards www.crnbc.ca/Standards/Lists/StandardResources/802MAiD.pdf Limits October 4, 2016 Conditions The CRNBC Board on Sep. 23, 2016 approved new and revised Scope of Practice standards, which take effect Feb. 28, 2017. These scope
standards can be accessed on the CRNBC website:
www.crnbc.ca/Standards/RNScopePractice/orders/Pages/Default.aspx They will be incorporated into the full Scope document once they are in effect.
T: 604.736.7331 2855 Arbutus Street College of F: 604.738.2272 Vancouver, BC Registered Nurses Toll-free: 1.800.565.6505 V6J 3Y8 Canada of British Columbia
SCOPE OF PRACTICE FOR REGISTERED NURSES
The scope of practice for registered nurses and nurse practitioners in British Columbia is set out in the Nurses (Registered) and Nurse Practitioners Regulation under the Health Professions Act.
Additional scope of practice information is included in CRNBC’s Bylaws and Standards of Practice.
The purpose of this document is to:
Explain the Regulation and those parts of the Health Professions Act that have an impact on scope of practice for registered nurses Set out CRNBC standards, limits and conditions related to scope of practice Explain the restricted activities for registered nurses that are outlined in the Regulation Explain delegation as it applies under the Health Professions Act and CRNBC Standards of Practice.
Information in this document is subject to change as CRNBC policy is revised or legislation is amended. CRNBC registrants will be notified of changes.
* Terms defined in the Glossary (Appendix 4) are highlighted in bold type in this document the first time they appear.
CRNBC Standards of Practice CRNBC is responsible under the Health Professions Act for setting standards of practice for
its registrants. CRNBC Standards include:
Scope of Practice Standards, Limits and Conditions These can be found on the CRNBC website www.crnbc.ca © Copyright College of Registered Nurses of British Columbia / January 2016 Effective date: March 1, 2016 2855 Arbutus Street, Vancouver, BC V6J 3Y8 Tel: 604.736.7331 or 1.800.565.6505 www.crnbc.ca Pub. No. 433
Part 1: The Basis for Scope of Practice
WHAT THE REGULATION COVERS
The Nurses (Registered) and Nurse Practitioners Regulation sets out, among other things:
1. Reserved titles for nurses
2. A scope of practice statement
3. Restricted activities for registered nurses and nurse practitioners Reserved Titles
CRNBC registrants can use the following reserved titles:
Nurse “Nurse practitioner” is also a reserved title under the Regulation. Only registered nurses who are registered with CRNBC in the nurse practitioner category can use the title “nurse practitioner” or “registered nurse practitioner.” More information about reserved titles can be found in the CRNBC Bylaws and the Practice Standard Appropriate Use of Titles available at www.crnbc.ca.
Scope of Practice Scope of practice refers to the activities that registered nurses are educated and authorized to perform. These activities are established through the legislated definition of nursing practice and are complemented by standards, limits and conditions set by CRNBC.
The Regulation states that registrants of CRNBC may practise nursing. Nursing is defined as the
health profession in which a person provides the following services:
Health care for promoting, maintaining and restoring health Prevention, treatment and palliation of illness and injury, primarily by assessing health status, planning and implementing interventions, and coordinating health services This definition does not refer to evaluation, but neither does it exclude it. Evaluation is, of course, an important part of nursing practice.
The Regulation does not refer to education, administration and research in the scope of practice statement for nurses or any other health professionals in B.C. However, CRNBC’s Professional Standards make it clear that clinical practice, education, administration and research are all considered part of the practice of registered nursing.
Exceptions Registered nurses provide care only within the scope of practice. There are two exceptions to
1. In situations involving imminent risk of death or serious harm that arise unexpectedly and require urgent action. Registered nurses are ethically obligated to provide the best care they can, given the circumstances and their individual competence.1
2. Where a formal delegation process is in place. See Part 4.
Restricted Activities Restricted activities are clinical activities that present a significant risk of harm to the public and are therefore reserved for specified health professions only.2 The Regulation assigns specific restricted activities to registered nurses. Restricted activities are discussed in Part 3.
STANDARDS, LIMITS AND CONDITIONSCRNBC has authority under the Health Professions Act to establish, monitor and enforce standards, limits and conditions for registered nurses’ practice.
Standard: A desired and achievable level of performance against which actual performance can be compared. It provides a benchmark below which performance is unacceptable.
Limit: Specifies what registered nurses are not permitted to do. For example, registered nurses may not carry out endotracheal intubation.
Condition: Sets out the circumstances under which registered nurses may carry out an activity. For example, registered nurses who order X-ray or ultrasound for the purpose of screening or triage or treating a condition must successfully complete additional education.
Whenever possible, CRNBC uses standards (rather than limits and conditions) to provide direction for practice.
1 Employers and nurses should not rely on the emergency exemption when an activity is considered an expectation of practice in a particular setting.
2 The B.C. government is currently developing a master list of restricted activities. The complete list of proposed restricted activities is available at http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/professional-regulation/scope-of-practice-reform. The Nurses (Registered) and Nurse Practitioners Regulation sets out the restricted activities from this list that are within the scope of practice of registered nurses.
CONTROLS ON NURSING PRACTICE
There are four levels of controls on registered nurses’ practice:
1. Nurses (Registered) and Nurse Practitioners Regulation, which sets out the scope of practice in fairly broad strokes.
2. CRNBC standards, limits and conditions, which complement and further define and limit the scope of practice set out in the Regulation.
3. Employer policies, which may restrict registered nurses’ practice in a particular agency or unit.
4. An individual registered nurse’s competence to carry out a particular activity.
Figure 1 illustrates the levels of control on registered nurse practice.
Figure 1: Controls on Practice
TWO KEY PRINCIPLESThe Health Professions Act and Regulation support and clarify two key principles that CRNBC
believes uphold safe nursing practice:
1. The scope of practice reflects the reality of registered nurse practice.
2. Clear responsibility and accountability among health professionals is fundamental to the provision of safe and ethical client care by competent nurses.
The Regulation supports the first principle by reflecting common practice of registered nurses. It supports the second principle by clarifying responsibility and accountability of registered nurses in their practice. For example, the Regulation makes clear that certain restricted activities may be carried out by registered nurses without an order, while other restricted activities require a client-specific order.
HOW PRACTICE IS DESCRIBED IN THE REGULATION
The Regulation sets out three kinds of practice:
1. General practice
2. Certified practice
3. Nurse practitioner practice General Practice In carrying out general practice activities, registered nurses move from novice to expert without
having to obtain any additional regulatory approval from CRNBC. General practice includes:
Activities that are restricted and activities that are not restricted Activities that registered nurses can carry out without an order and activities that require a client-specific order Sections 6 and 7 of the Regulation list the restricted activities that registered nurses may carry out as part of general practice.
Although no additional regulatory approval is needed to carry out general practice activities,
CRNBC has the authority to determine the following:
Which activities are considered the practice of nursing within the scope of practice set out in the Regulation Any standards, limits and conditions that may apply Registrants who are in doubt about whether some aspect of their practice falls within the scope of registered nurse practice should contact CRNBC for clarification. Registered nurses are required to follow the standards, limits and conditions set by CRNBC.
Certified Practice Section 8 of the Regulation describes some restricted activities as certified practices. Registered nurses cannot carry out these activities (or carry them out without an order) until they have been certified by CRNBC.
Nurse Practitioner Practice Section 9 of the Regulation describes restricted activities for nurse practitioners. The scope of practice of nurse practitioners includes all activities within the scope of practice of registered nurses. As with registered nurses, an activity within the scope of practice of nurse practitioners may not be within an individual nurse practitioner’s competence.
See Appendix 3 for a graphic model that reflects registered nurses’ scope of practice.
Part 2: Activities That Are Not Restricted Most activities that registered nurses carry out do not involve performing restricted activities.
The Regulation includes these activities in the broad scope of practice statement. They are fundamental to registered nurse practice and many are complex.
EXAMPLES OF NURSING ACTIVITIES THAT ARE NOT RESTRICTED:
Assisting clients with activities of daily living Carrying out an electrocardiogram Communicating appropriately with clients, colleagues and others Collaborating with others on the health care team Coordinating care services for clients
Developing professional relationships with clients and others Documenting timely, accurate reports Managing or applying physical restraints
Providing some disease prevention and health promotion services (e.g., blood glucose screening) Recommending or administering some medications (e.g., Schedule III drugs)
LIMITS AND CONDITIONS ON ACTIVITIES THAT ARE NOT RESTRICTED
CRNBC has established limits and conditions for two activities that are not restricted:
Cardiac Stress Testing Financial Incapability Assessment
1. Cardiac stress testing for the purposes of diagnosis and treatment planning. This activity is not included in government’s current list of restricted activities. While few registered nurses carry out this activity, it carries a significant degree of risk to the client.
CRNBC Limits and Conditions Registered nurses may only carry out cardiac stress testing under a physician’s direction and only following successful completion of additional education.
2. Registered nurses acting as qualified health care providers under the Statutory Property Guardianship Regulation.
CRNBC Limits and Conditions Registered nurses may act as qualified health care providers under Part 2.1 of the Adult Guardianship Act for the purpose of conducting the functional component of a financial incapability assessment in accordance with Part 3 of the Statutory Property Guardianship Regulation under that Act, if they Successfully complete the Ministry of Health course “A Guide to the Certificate of Incapability Process under the Adult Guardianship Act”; and Successfully complete additional education related to clinical practice in this area.
Registered nurses acting as qualified health care providers under Part 2.1 of the Adult Guardianship Act must also follow the Ministry of Health and Public Guardian and Trustee’s procedural guide, “A Guide to the Certificate of Incapability Process under the Adult Guardianship Act.”