Being a Nurse – More Than Just Tasks
Deciding what not to do is as important as deciding what to do
Within Canada, nurses' scope of practice is varied between jurisdictions, often poorly understood and way too often defined on the basis of tasks. Nurse leaders generally recognize that defining the practice of nurses solely on the basis of tasks only serves to devalue the critical thinking and evidence-base of the profession. But nurses themselves have also frequently fallen into the trap of delineating their practice in terms of tasks and time. An unfortunate outcome of this task orientation is a lack of appreciation for the full breadth of nurses' knowledge and scope of practice capabilities. In the extreme, (as I recently read in a letter to the editor) this leads to the conclusion that one doesn't need a university education to be a nurse – hospital-based training schools did the job just fine.
Scope of practice is "dynamic and responsive to changing health needs, knowledge development and technological advances" (International Council of Nurses [ICN] 2013). The ICN's position statement on scope of practice delineates that governments have a responsibility to:
"provide legislation which recognises the distinctive and autonomous nature of nursing practice including a defined scope of practice that is reflective of nurses' capabilities as well as flexible and responsive to the dynamic nature of health care delivery and the public's health care needs" (p.1).
Further, it designates employers as having an obligation to:
"support nurses in practicing to and within their full scope of practice. This includes not placing nurses in situations where they are being asked to practice beyond their level of competence or outside their legal scope of practice and providing practice environments that support safe and competent practice" (p. 1).
More often than not, the employer obligation falls to the purview of nurse leaders. Although guided by legislation and regulation, decision-making about the practical and ethical use of nursing resources is largely based upon historical practices, the mix of healthcare professionals available within a given setting and geographic region as well as fiscal constraints. Given varied understandings of nursing practice, and cross-country differences in the operationalization of nurses' roles, how then do we advocate for the optimization of nurses' scope of practice and articulate the benefits of same for improvements to healthcare delivery in Canada?
As the unfolding of healthcare delivery continues to be somewhat uncertain and workforce planning remains reactive in many jurisdictions, it is imperative to examine the optimization of health professions' scopes of practice in conjunction with options for new models of care. For a thorough, evidence-informed synthesis of the issues and targeted directions for transforming health service delivery in Canada, I refer you to the extremely comprehensive analysis and recommendations provided by Nelson, Turnbull and colleagues (2014). While completed 5 years ago, the recommended directions for new models of care and optimized scopes of practice have been yet to be embraced by government and healthcare leaders.
Furthering the dialogue about scopes of practice and the possibilities for innovative models of care is particularly important given the emergence of new roles (e.g., physician assistants) and the continued under-utilization of others (e.g., nurse practitioners [NPs]). Additionally, given the dearth of specific health professions and specialists in certain parts of the country, it is clear that we need to elevate the collective understanding of policy-makers and healthcare decision-makers as to the potential contributions of all health professions. In addition, we need more research to support the most appropriate and cost-effective allocation of resources within specific care settings and sectors, and in support of specific clinical populations. As a case in point, primary care provider shortages prevail in many parts of the country, while unemployed NPs could more than adequately fill the gap. Arguments against the expanded use of NPs wage on in spite of decades of evidence lending support for their clinical and financial effectiveness. In fact, when one examines the educational preparation, knowledge and skills of various categories of health professionals, it becomes patently clear that there is much overlap and common ground in their knowledge and skills that are being grossly underutilized.
What we know with some certainty: healthcare is costly, the recruitment, retention and deployment of health human resources within provincial and territorial jurisdictions is difficult to control, and there are health professionals being underutilized (e.g., NPs) while others are being pushed to practice beyond their regulated scopes of practice.
In this issue, our contributors have highlighted many of the issues that challenge and influence scope of practice for registered nurses and licensed practical nurses. Two papers by McLeod and colleagues (2019a & 2019b) address the scope of practice of RNs and licensed practical nurses (LPNs) in rural and remote settings. More specifically, they examined predictors of registered practical nurses working below (2019a) and registered nurses practicing beyond their designated scope of practice (2019b). These studies underscore the important roles of government, employers, nurse leaders and regulators in supporting the enactment of appropriate scopes of practice.
Consistent with the ICN position statement (2013), Lankshear and Martin (2019) describe the "impermanence" of scopes of practice, emphasizing the ever-evolving complexities of healthcare. To this end, nurses need to be flexible in order to optimize their contributions to care in the face of changing legislation, regulation, education, and organizational landscapes. Fraser and colleagues examine the role and scope of LPNs in home care and case management functions. They highlight a lack of clarity and consistency in role operationalization as in some settings they have a designated "case manager" role and in other settings LPN's perform some case management functions. Overall their finding that factors such as personal preference, needs of a given setting, and the availability of supports (e.g., mentors and collaborative practice) all impact how LPN practice is operationalized.
In their integrative review of national nursing codes of ethics for nurse leaders, Schick-Makaroff and Storch argue that ethical leadership is an important pre-requisite to the realization of ethical practice in healthcare. One might extrapolate from their review and discussion, the importance of having a code of ethics that clearly guides a scope of practice, particularly that of nurse leaders. After all, it is the formal leader who takes responsibility for the appropriate allocation of resources with the requisite skills and professional capabilities to meet client needs in a given setting.
Surani and colleagues (2019) describe the process and outcomes of an approach to engage and empower nurses at a large urban mental health and addictions teaching hospital. An unexpected finding was the lack of a consistent understanding of nurses' roles, even in the context of an organization focused on a specific clinical population. As a result, they were purposeful in their efforts to provide various stakeholders with an explication nursing's scope of practice. The creation of a "movement" such as they describe might well be a mechanism by which the work of nurses can be further illuminated.
Collectively our contributors to this issue, have identified considerations and factors to not only maximize nurses' scope of practice but also to elevate ethical practice and explicate the value of all nurses' contributions to healthcare in urban, rural and remote settings. However, what remains clear is that the vision and recommendations outlined in the Canadian Academy of Health Sciences expert panel report (Nelson et al, 2014) have yet to be realized – the promise and possibility for new models of care that optimize the use of all health human resources remains unfulfilled. Nurses are fundamentally more than the sum of their tasks – let's advocate for a recognition and inclusion of possibilities to advance nurses' full scopes of practice for the sake of equitable and affordable Canadian healthcare.
Lynn M. Nagle, PhD, RN, FAAN
University of Toronto
University of New Brunswick
Fraser, K., Punjani, N.S., Wilkey, B., Labonte, S., Lartey, S., Gubersky, J., Nickoriuk, K., Joseph, S., Younus, S., & Miklavcic, J. (2019). "Optimizing Licensed Practical Nurses in Home Care: Their Role, Scope and Opportunities." Canadian Journal of Nursing Leadership 31(1): 42–59. doi:10.12927/cjnl.2019.25849.
International Council of Nurses (2013). Position Statement: Scope of Practice. Retrieved May 15, 2019. <https://www.icn.ch/sites/default/files/inline-files/B07_Scope_Nsg_Practice.pdf>.
Lankshear, S. & Martin, D. (2019). "Getting Comfortable with ‘It Depends’: Embracing the Impermanence of Scope of Practice." Canadian Journal of Nursing Leadership 31(1): 30–41. doi:10.12927/cjnl.2019.25850.
MacLeod, M.L.P., Stewart, N.J., Kosteniuk, J.G., Penz, K.L., Olynick, J., Karunanayake, C.P., Kilpatrick, K., Kulig, J.C., Martin-Misener, R., Koren, I., Zimmer, L., Van Pelt, L. & Garraway, L. (2019a). "Rural and Remote Registered Nurses' Perceptions of Working Beyond Their Legislated Scope of Practice." Canadian Journal of Nursing Leadership 31(1): 20–29. doi:10.12927/cjnl.2019.25851.
MacLeod, M.L.P., Stewart, N.J., Kosteniuk, J.G., Penz, K.L., Olynick, J., Karunanayake, C.P., Banner, D., Wilson, E., Kulig, J.C., Labreque, M.E., Moffitt, P., Jahner, S. & Garraway, L. (2019b). "Rural and Remote Licensed Practical Nurses' Perceptions of Working Below Their Legislated Scope of Practice." Canadian Journal of Nursing Leadership 31(1): 8–19. doi:10.12927/cjnl.2019.25852.
Nelson, S., Turnbull, J., Bainbridge, L., Caulfield, T., Hudon, G., Kendel, D., Mowat, D., Nasmith, L., Postl, B., Shamian, J., Sketris I. (2014). Optimizing Scopes of Practice: New Models for a New Health Care System. Canadian Academy of Health Sciences. Ottawa, Ontario.
Schick-Makaroff, K. & Storch, J.L. (2019). "Guidance for Ethical Leadership in Nursing Codes of Ethics: An Integrative Review" Canadian Journal of Nursing Leadership 31(1): 60–73. doi:10.12927/cjnl.2019.25848.
Surani, Z, Strudwick, G., Purushuttam, L., & Srivastava, R. (2019). "Process and Initial Outcomes of an Initiative to Engage Nurses at a Mental Health and Addictions Hospital." Canadian Journal of Nursing Leadership 31(1): 74–85. doi:10.12927/cjnl.2019.25847.
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