College of Nurses Aotearoa
Submission on the Registered Nurse Scope of Practice
July 2009
The College of Nurses (Aotearoa), “the College”, is a professional body of New Zealand nurses from all regions and specialities both within and outside of the District Health Board setting. It provides a voice for the nursing profession and professional commentary on issues that affect nurses, and also the health of the whole community.
Contact for this submission:
Professor Jenny Carryer, RN, PhD, FCNA(NZ), MNZM
Executive Director
College of Nurses (Aotearoa)
Clinical Chair of Nursing
Massey University / MidCentral District Health Board
PO Box 1258
PALMERSTON NORTH
Tel: 027 449 1302
Email: J.B.Carryer@massey.ac.nz
General consultation questions
1. Do you think the issues for the registered nurse scope of practice are clearly outlined in this consultation document?
X Yes
This proposal is a substantial professional and strategic issue, probably one of the most significant ‘tipping’ points in the profession for the last 10 years.
New Zealand is not alone in reviewing how regulation of health professionals can support workforce flexibility; reflect changes in clinical practice and maintain oversight of the health and safety of the New Zealand public. This response recognises that the clinical environment and nursing practice have changed and endeavours to remain abreast of these issues are in the public interest.
The College holds the view that
- the regulatory body alone can determine changes or extensions to a scope of practice
- the profession should agree and set standards and guidelines for practice
- the employer has a role in credentialling related to appropriate employment of the right person and provision of a safe environment ( facilities, capacity, resources, professional development etc)
The College would also like to refer the Nursing Council to the recent work by the National Nursing Organisations in
- developing nationally consistent definitions to describe nursing practice in a shortly to be released glossary,
- devising a plan for professional cohesion on standards endorsement
- attending to the reduction of evidential requirements of the PDRP program and increasing uptake of the program.
2. Do you think that the appropriate criteria for decision making on the registered nurse scope of practice are outlined on page 17?
X No
3. If no, what criteria would you include:
The College vision is: 100% Access – Zero Disparities. The criteria should include reference to improving access to health services and the potential to address health disparities for high needs/vulnerable populations. This is not explicit in the current list of criteria.
Option 1 consultation questions
4. Do you support changing the wording of the registered nurse scope statement to allow nurses to expand their practice?
X Yes
5. Please explain
Option 1 captures a substantial amount of what is already custom and practice for many nurses now. What has been missing is an appropriate regulatory statement to support this.
Option 1 enables flexibility on the part of the RN and the ability to expand their practice as well as the ability to work with vulnerable populations such as Maori whanau in a culturally safe practice.
Option 1 effectively includes Option 4 in the scope statement. Further clarity on what Registered Nurses can do on completion of an undergraduate programme and what parts of the scope statement can be achieved post-registration is still needed. For example, consideration of a Part A and B approach to the Registered Nurse scope could be feasible.
The College would also like to support the inclusion of nurse prescribing as one of the components of the scope statement.
6. If yes, do you support the wording changes outlined in option 1?
X yes
7. If you prefer other wording, please outline the wording you would prefer:
The College would like to recommend the scope statement is considered in two parts. Part A would apply to all Registered Nurses on registration. We believe provisional registration should be discussed by the profession.
Part B would apply to Registered Nurses who have the appropriate experience, skills and knowledge, and have completed an entry to practice program. The statement regarding conditions of practice could then be moved to the end of the scope statement if it is the intent that these conditions apply to Part B.
Increasingly, family/ whanau members are/ will be the primary care caregivers for patients/ clients. While the College is reluctant to add more supervisory responsibilities to Registered Nurses, this addition does reflect current practice.
The use of the term ‘client’ is applicable but does imply that people have a choice of nurse or health care service provider which becomes increasingly unlikely. In addition the term patient is applicable to many settings and acceptable to the general public.
We consider that the inclusion of a specific statement regarding the performance of procedures under medical delegation is a critical point and should be used with extreme caution. We have therefore (in brackets below) made a clear differentiation that it is only surgical or operative procedures which should be done under medical delegation. The addition of assessment, diagnosis and prescribing could be noted as “defined or limited” in order to make the distinction between RN and NP practice
College of Nurses wording changes are in [brackets].
[A] Registered nurses use nursing knowledge and judgment to assess health needs and provide care, and to advise and support people to manage their health. They practise independently and in collaboration with other health professionals, perform general nursing functions and delegate to and direct enrolled nurses, nurse assistants and [unregulated healthcare workers]. They provide comprehensive [patient/]client assessments to develop, implement, and evaluate an integrated plan of health care, and provide interventions that require substantial scientific and professional knowledge and skills. This occurs in a range of settings in partnership with individuals, families, whanau and communities. Registered nurses may practise in a variety of clinical contexts depending on their educational preparation and practice experience. Registered nurses may also use their expertise to manage, teach, evaluate and research nursing practice.
[B] {Registered nurses with appropriate experience, additional education and clinical knowledge and skills may undertake defined diagnostic and treatment interventions within a multidisciplinary team. These nurses may also make defined advanced assessments, diagnose, [prescribe] and treat clients within a multidisciplinary team or as part of a nurse led service.
Some surgical or operative procedures may also be performed under medical Delegation.
[There will be conditions placed in the scope of practice of some registered nurses according to their qualifications or experience limiting them to a specific area of practice.]
8. Do you think the preparation (initial qualification e.g. Bachelor of Nursing) for registered nurses needs to change as a result of changes in the scope statement?
X yes
The College recognises that internationally there are a number of countries moving towards the establishment of a 4 year degree. IN addition the majority of health professionals with far more limited scopes now have 4 year degrees. Further analysis of the impact of this change and what New Zealanders expect of a Registered Nurse is required but not covered in the scope of this submission.
As noted we would like to raise debate about conferring provisional registration only until completion of an entry to practice program as a critical public safety issue
Investment and support for post-entry clinical training and education that will in effect enable Registered Nurses to achieve their full potential and the proposed scope statement is essential.
9. Any other comments on option 1?
The scope statement needs to retain flexibility as well as being future orientated. The vision of nursing/ health care practice over the next 20 to 30 years needs to be considered in this scope statement.
Option 2 consultation questions
10. Do you support credentialling as a way of ensuring nurses undertaking expanded practice are competent?
[ ] Yes
11. Please provide reasons
The College has participated in the MoH National Working Party and in partnership with NZNO noted that
Professional Association View
The New Zealand Nurses’ Organisation and the College of Nurses, Aotearoa believe that nursing needs to be responsive and flexible in meeting future health need. An enabling scope of practice will allow the evolution of a quality nursing service. Nursing is constantly responding to changes in health service provision and patient care and treatment approaches. At times this means taking on new responsibilities such as procedural techniques which may have traditionally been undertaken by other health professionals. This is always in the context of nursing practice. In these circumstances the credentialing process to ensure public safety needs to assure that a nationally consistent standard is applied, that employing organisations have policies in place which support the nurse undertaking the extended activity, that nurses have the level of knowledge and skill appropriate to undertake the activity independently and that the quality and outcome is monitored.
The respective roles of the regulation authority, the professional associations and the employing organisations in credentialing extensions to practice are not clear at present. It is the view of the professional associations that they set the standards of practice and that a national system is required to implement and recognise those standards in the employment situation. The importance of one to one feedback at annual appraisals and professional development planning meetings cannot be underestimated in a quality improvement system and this process needs to occur for everyone. It is also the view of the professional associations that credentialing of extended practice for nurses should occur within the employment setting and to a consistent national standard and that the regulation authority should regulate scopes of practice using authorisation only in a very limited range of situations.
12. Do you support professional organisations such as the New Zealand Nurses Organisation and the College of Nurse Aotearoa setting the standards for expanded practice?
X Yes
13. Please provide reasons
Professional associations are in a strategic position to set standards and achieve national consistency and this work is now in process.
14. If so, what roles/activities do you think should be credentialled?
Credentialing frameworks are embryonic and not yet well understood. The development of agreed national standards and credentialing processes is still to be agreed.
Credentialing should apply to activities – not roles.
15. Any other comments on option 2?
The cost of credentialing is unknown. If the medical credentialing approach is used, then either subscription costs or similar paid by the individual practitioner or their employer are likely to increase. This may create barriers to care or increase the cost of care.
The College believes that uptake of current professional development programmes still requires support and investment. These programmes are able to provide assurance that the vast majority of the nursing workforce is fit for practice. These programmes will require modification if they are to apply to extend areas of practice.
Option 3 consultation questions
16. Do you support authorisation of specific extended activities by the Council?
X No
17. Please provide reasons
There may well be activities which fall outside of the current legislation and/or regulatory frameworks which would require Council oversight. However, the College sees this role as exceptionally limited.
There may also be a transition time required as authorisation type activities are transferred over to professional associations /employers and credentialing frameworks are implemented.
18. If yes, what roles/activities do you think should be authorised?
As above.
19. Any other comments on option 3?
Option 4 consultation questions
20. Do you support a new scope of practice for registered nurses?
X No
21. Please provide reasons
The College believes that Option 1 with aspects of option 2 provides the flexibility and mechanism for supporting public safety and that a new scope is not required.
There is sufficient confusion with the existing scopes of practice for the public and employers, without adding additional complexity and artificial boundaries in nursing practice.
Some of the issues that have led to this option are based more on ‘job titles’; the lack of standardisation of training/ education for specialist roles or shared meaning of expanded practice. These issues can be addressed through the development of a national consistent language and definitions, rather than creation of a new scope of practice.
22. Please comment on the wording of the scope statement
23. Comment on the title for this scope of practice
Not required.
Additional consultation questions
24. Are there any other options the Council should consider?
Any changes to the Registered Nurse Scope of Practice will require a significant communication plan/ strategy.
Disciplinary processes will need to be reviewed and guidance provided to Tribunal members on what would or would not constitute a nurses scope of practice which may be subject to interpretation. Alignment with other regulatory bodies may be of some value.
25. Please note any further comments you have.
No further Comments.
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