Expansions in scope of practice of health professionals, including physicians, have been in response to numerous factors including health workforce shortages, increasing patient needs, scientific and technological discovery, personal interests and professional aspirations. These changes, which are generally bolstered by broadened curricula and training, are occurring within and outside of interprofessional or collaborative care models and have often improved all facets of health care. Health professionals can thus assume new scopes of practice independently or under supervision.
As the scope of practice of other health providers outside of medicine expand to encompass varying levels of clinical judgment in the diagnosis and treatment of patients, they are playing an important role in patient care and helping improve access. For example, pharmacists are now able to prescribe medications or administer drugs by injection in select provinces (1). Nurse practitioners in Manitoba can order diagnostic tests (2) and in Prince Edward Island they can take an independent caseload of patients (3). Midwives and podiatrists have been federally authorized to prescribe controlled substances (4). Unfortunately, not all health professions are regulated in every province and territory nor are they subject to the same provisions (a).
Recognizing the many benefits of evolving scopes of practice, precautions must also be in place to ensure that patient safety and wellbeing are safeguarded as all health professional’s’ scopes of practice evolve. Accordingly, the Royal College believes that the scope of practice of all health professionals, from graduation to retirement, should be subject to the highest standards of education, and reinforced by ongoing research and professional and regulatory oversight.
Principles
Health professionals are regulated or overseen by provincial and territorial governments and regulatory authorities, which are thus ultimately responsible for safety, competence and quality. To maintain patient safety and wellness during the uptake of new or redesigned scopes of practice of health providers, the Royal College calls on regulators and governments to respect the following principles:
Scope of practice should always be consistent with quality specialized skills training and education of the health provider, underscored throughout the continuum of education. This includes a review of the accreditation process of educational programs and the learning activities pursued through continuing professional development.
Significant differences exist in the definition, scope, admissions prerequisites, and length of training (5) between physicians and other health care professionals.
- Is the expanded scope of practice appropriate for the practitioner’s education, training and examination requirements? Do existing education and training assure needed competencies to perform news skills moving forward?
- If the change in scope is an advanced skill that is tested on the entry-level licensure examination or that has to be measured after licensure has been obtained, how is competence in the new technique assured, including the ability to deal with the consequences of treatment, services, and care such as complications?
- What provisions exist to ensure that practitioners maintain competency in the delivery of services? (6 & 7)
Research and data on population health needs, patient health outcomes, patient satisfaction and health system performance including cost effectiveness should be critical markers of evidence, ensuring quality of care.
- Firstly, is there supporting evidence that establishes the population health needs that merit changes in the profession’s scope of practice?
- Research literature should be of sufficient rigor and scale that captures the full breadth of competencies that the professional brings to their practice to validate generalization of the results to the general population.
- Evaluation of changes of scope of practice should be built into appropriate provincial/territorial regulation to ensure that the change is actually having the impact that is intended, such as improved access, more efficient delivery of services etc.
- Given that this issue is occurring on a national scale, provincial/territorial knowledge sharing is crucial in this area.
Earnest consultations, communications and collaboration should be undertaken with key stakeholders including the physician profession and the public when significant changes to scope of practice are being considered or implemented.
- Key stakeholders, including the medical profession should receive adequate notice of scope of practice reviews, with background information and evidence supporting the proposed changes and sufficient time for feedback. Given that the expanded scope of health professionals often complement or substitute acts and services provided by physicians and surgeons who have extensive training throughout their professional lifecycle, they are able to provide informed opinions on proposed changes in the interest of the public.
- Formal collaboration is essential when implementing changes to scope of practice, in the interest of patient safety and the sound functioning of the health care system. If the broadened scope of practice has potential for adverse outcomes for which they have not been formally trained, the practitioner should have formally established collaborations with health professionals who have the knowledge, skills and training to deal with these complications. Changes to scopes of practice must also consider cross-impacts on other health professionals and the health system more generally.
- Patients should be well informed about changes in education and credentials of the practitioner to ensure accountability and transparency in delivery of care. Patients, who ultimately want to move toward seamless care between health professionals and services, can provide useful insights on health care delivery and scope of practice redesign.
- Designations should clearly identify the licensure or credential held by the health professional and the use of titles should not overlap or resemble existing credentials of licensed or credentialed practitioners to avert confusion amongst the public and health professions.
Conclusion
All health professions have a fundamental commitment to the health and wellbeing of the patient. The principles outlined above do not reflect interests of “turf protection” or income. The spirit of this position statement is focused on prioritizing patient access to care by the most competent and qualified health providers, through their training and continuing professional development. To do so otherwise merely compromises patient safety, is not cost effective and does not ensure all patients receive the quality of care they deserve.
Moving forward, we strongly encourage regulators and governments to apply a collaborative, inclusive, and transparent approach in their decision making process about scopes of practice. We would also suggest taking note of the numerous examples of successful interprofessional care models in the country that have been developed in a collaborative fashion among professions, adapting as training models evolve and utilizing the scope of a health professional’s abilities to its fullest extent, always putting patient wellbeing and safety first (b).
For additional information please contact
Royal College Office of Health Policy and Communications — healthpolicy@royalcollege.ca
Approved by Royal College Council in June 2013: Resolution No. 2013/14-23; ECC: 2013-05-22; C: 2013-06-17/18
References
1. Canadian Pharmacists Association. Summary of Pharmacists’ Expanded Scope of Practice Activities across Canada:
http://blueprintforpharmacy.ca/docs/kt-tools/pharmacists’-expanded-scope_summary-chart—cpha—janaury-31-
2013.pdf
2. Province of Manitoba. News Release : Nurse Practitioners can now order life-saving MRI tests :
http://news.gov.mb.ca/news/index.html?archive=2013-02-01&item=16716
3. The Guardian. Nurse practitioners taking on greater health-care role: http://www.theguardian.pe.ca/News/Local/2012-
12-05/article-3133902/Nurse-practitioners-taking-on-greater-health-care-role/1
4. Government of Canada. New classes of Practitioner regulations: http://canadagazette.gc.ca/rp-pr/p2/2012/2012-11-
21/html/sor-dors230-eng.html
5. Royal College Discipline Recognition Policy:
http://www.royalcollege.ca/portal/page/portal/rc/credentials/discipline_recognition
6. Federation of State Medical Boards. Assessing Scope of Practice in Health Care Delivery. http://www.fsmb.org/pdf/2005_grpol_scope_of_practice.pdf
7. Changes In Healthcare Professions’ Scope of Practice: Legislative Considerations:
https://www.ncsbn.org/ScopeofPractice_09.pdf
a. For example, physician assistants are regulated in the provinces of Manitoba and New Brunswick and not in Alberta and Ontario (Canadian Association of Physician Assistants: www.capa-acam.ca/features/faq/). Similarly, paramedics are a regulated health profession in Alberta but not in Ontario; they also have different educational requirements and classifications.
b. There are many successful examples of collaboration among and between health professions. The Society of Obstetricians and Gynaecologists of Canada has created a membership category, and established bursaries and educational programs for midwives (Society of Obstetricians and Gynaecologists of Canada: www.sogc.org). The Eye Health Council of Ontario was established to promote inter-professional collaboration and improve access, among other objectives. This is done by ensuring the most effective use of the continuum of eye care professionals and development of common collaborative guidelines for patient care in the interests of patient safety, quality of care, and cost-effective delivery (Eye Health Council of Ontario: http://www.ehco.ca/AboutUs.aspx).
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