N

FRAMEWORK FOR THE PRACTICE OF REGISTERED NURSES IN 2015 All rights reserved. No part of this document may be reproduced, stored in a retrieval system, or transcribed, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission of the publisher. © Canadian Nurses Association 50 Driveway Ottawa, ON K2P 1E2 Tel.: 613-237-2133 or 1-800-361-8404 Fax: 613-237-3520 Website: www.cna-aiic.ca ISBN 978-1-55119-431-8 November 2015 Framework for the Practice of Registered Nurses in Canada. — 2nd ed. * CANADIAN NURSES ASSOCIATION and the CNA logo are registered trademarks of the Canadian Nurses Association/Association des infirmières et infirmiers du Canada. TABLE OF CONTENTS Acknowledgments ...... 2 Introduction ...... 3 Key Elements of the Framework...... 5 Definition of the RN ...... 5 Conceptual Foundation of the Practice of RNs ...... 6 Professional Practice ...... 7 Registration and Licensure ...... 9 Values ...... 9 Entry-Level Competencies ...... 10 Educational Preparation ...... 11 Scope of Practice ...... 14 The Development of Expertise and Continuing Competence ...... 17 Professional Conduct ...... 19 RN Careers ...... 19 Roles and Practice Settings ...... 19 Career Paths ...... 21 The Impact of RNs ...... 23 Looking to the Future ...... 25 Glossary ...... 27 APPENDIX A: Definitions of Values in the CNA Code of Ethics for Registered Nurses...... 29 APPENDIX B: Examples of Regulatory Body Entry-level RN Competency Statements ...... 30 References ...... 32

Framework for the Practice of Registered Nurses in Canada Acknowledgments The Canadian Nurses Association gratefully acknowledges the dedication, commitment and contribution of the members of the framework advisory committee, who participated in the development of this document.

Registered Nurse Framework Advisory Committee Cynthia Baker Lori Lamont Canadian Association of Schools Winnipeg Health Authority of Joanne Maclaren Liette Clement Association of Registered Nurses of Nurses Association of Barbara Foster Lynn Power Health Canada Association of Registered Nurses of Newfoundland and Labrador Audrey Fraser Association of Registered Nurses of Linda Smyrski Health, Healthy Living and Seniors Jan Inman Registered Nurses Association of Pauline Worsfold Northwest Territories and Nunavut Canadian Federation of Nurses Unions

Canadian Nurses Association Josette Roussel Lisa Little

2 || FRAMEWORK || Introduction Registered nurses (RNs) practise in all of The framework contains the following Canada’s provinces and territories across key elements: the five domains of practice: clinical care, „ education, administration, research and Definition of the RN policy. In many settings, RNs „ Theoretical Foundation of RN Practice care for people around the clock, seven „ Professional Practice days a week, while making vital contribu- • Registration and Licensure tions to positive client1 outcomes, to the effective functioning of health-teams and • Values to the sustainability of the health-care • Entry-level Competencies system. Provincial/territorial legislation • Educational Preparation and regulations are used to grant quali- fied nurses the legal authority to use the • Scope of Practice title “registered nurse” or “RN.” • Continuing Competence This framework seeks to promote a • Professional Conduct common understanding of RN practice „ RN Careers among nurses, students and stakehold- ers in Canada (including other health • Roles and Practice Settings professionals, employers, educators, • Career Paths policy-makers and the public). Given „ The Impact of RNs the large number of regulated and unregulated care providers, it is essen- „ Looking to the Future tial for policy-makers, decision-makers and employers to clearly understand RN For the purposes of the framework, it competencies and contributions as well is also important to acknowledge the as to know when RN care is the most dynamic nature of an RN’s education, appropriate. In addition, the framework regulation and practice, which develop is meant to be a resource for RNs who in response to population health needs, are working with others to develop advancements in nursing knowledge and a health-care system that is more changes in the health-care system. Since responsive to the needs and priorities regulation is set at the jurisdictional of Canadians. In carrying out this goal, level (i.e., by the provinces and territo- it is important to build on RNs’ current ries) slight variations in language and practice in determining the roles RNs processes are inevitable; however, the will assume to strengthen the system. principles shared in this document are pan-Canadian in scope.2

1 Terms in bold are defined in the glossary. 2 The specific regulations for RNs in each province and territory can be found on the regulatory body websites listed at https://www.cna-aiic.ca/en/becoming-an-rn/regulation-of-rns/regulatory-bodies.

Framework for the Practice of Registered Nurses in Canada 3 4 || FRAMEWORK || Key Elements of the Framework DEFINITION OF THE RN The Canadian Nurses Association defines the RN as follows: RNs are self-regulated health-care professionals who work autonomously and in collaboration with others to enable individuals, families, groups, communities and populations to achieve their optimal levels of health. At all stages of life, in situations of health, illness, injury and disability, RNs deliver direct health-care services, coordinate care and support clients in managing their own health. RNs contribute to the health-care system through their leadership across a wide range of settings in practice, education, administration, research and policy.

Framework for the Practice of Registered Nurses in Canada 5 In Canada, the nursing profession con- the metaparadigm of the discipline, sists of four regulated nursing groups: these concepts are (1) the person or registered nurses (RNs), nurse practi- client, (2) the environment, (3) health, tioners (NPs),3 licensed practical nurses4 and (4) nursing (Kozier et al., 2013; and registered psychiatric nurses.5 RNs See Figure 1). make up almost three-quarters of the regulated nursing workforce and are the Figure 1. Metaparadigm of Nursing country’s largest single group of health- care providers (Canadian Institute for Health Information [CIHI], 2015).

The regulation of RNs is more specifically Person defined in jurisdictional legislation, e.g. Health in RN acts and other documents (such as standards of practice) developed by provincial and territorial regulatory bodies. Environment CONCEPTUAL Nursing FOUNDATION OF THE PRACTICE Source: Adapted from Ordre des infirmières et infirmiers OF RNS du Québec, 2010, p. 7. Conceptual Framework As Kozier et al. (2013) point out, “philosophical thinking provides the In the nursing metaparadigm, the person foundation for the development and or client refers to the beneficiary of RN Professional critical analysis of nursing knowledge. care, which may be an individual,Responsibility family, and Nursing knowledge is organized and group, community or population.Accountability RNs Knowledge- communicated by using concepts, mod- focus on wholeness, considering the based Practice els, frameworks and theories (p. 62).” biophysical, psychological, emotional, Four central concepts underpin the social, cultural and spiritual dimensions Client Individuals conceptual and theoretical frameworks of the client. In addition, RNs are atten- Families for RNs. Frequently referred to as tive to their clients’ environment,Self- taking Groups Regulation Communities Populations Ethical Practice

Service to the Public

3 This document excludes (or RN in the extended class in ) practice, which is covered in CNA’s Advanced Nursing Practice: A National Framework. 4 In Ontario, the title used for a is “registered practical nurse.” 5 Registered psychiatric nurses are currently educated and regulated only in British Columbia, , , Manitoba and the Yukon.

6 || FRAMEWORK || into account the broader determinants of health, which include social, physical, PROFESSIONAL psychological and economic factors PRACTICE that may affect them (Canadian Nurses Canadians have given the nursing pro- Association [CNA], 2013). An RN’s concern fession the privilege of self-regulation. with health has many facets, including the Provincial and territorial governments levels of wellness, well-being and quality mandate and delegate to nursing reg- of life their clients’ experience. The pro- ulatory bodies (by statute) the power to fession of nursing for RNs “encompasses regulate themselves and to ensure the autonomous and collaborative care of profession remains accountable to the individuals of all ages, families, groups public and to governments. Regulatory and communities, sick or well and in all bodies achieve this mandate by ensuring settings. Nursing includes the promotion that RNs are safe, competent and ethical of health, prevention of illness and the practitioners through a variety of regula- care of ill, disabled and dying people. tory activities. Advocacy, promotion of a safe environ- ment, research, participation in shaping In return, the nursing profession is at all health policy and in patient and health times expected to act in the best interest systems management, and education of the public. To maintain public protec- are also key nursing roles” (International tion, RNs engage in self-regulation as a Council of Nurses, 2014). profession and as individuals. Nursing science is the foundation of These mandated responsibilities for nursing practice, although RNs use regulatory bodies and individual RNs also knowledge from a variety of sciences include governments, the public, educa- and humanities to inform their practice. tional institutions, employers, and other These include basic science, social health-care professions and professionals and behavioural sciences, psychology, (CNA, 2007). Some examples are shown complexity theory, etc. in Table 1.

Framework for the Practice of Registered Nurses in Canada 7 Table 1. Examples of self-regulatory activities of the nursing profession and individual RN

Profession (regulatory body) Individual RN

Establishes registration and Meets initial and ongoing licensure/ licensing processes registration requirements

Establishes, monitors and enforces Adheres to the code of ethics and standards in ethics and practice standards of nursing practice

Establishes and maintains the scope Practises within the established of RN practice as health-care delivery scope of practice and nursing knowledge advances

Establishes nursing education Graduates from an approved nursing standards and approves nursing program. Contributes to curriculum education programs leading to development initial entry to the profession Acts as a mentor and preceptor for nursing students

Establishes and maintains Demonstrates entry-level competen- entry-level competencies cies by passing the pan-Canadian required for initial registration registration exam6 Contributes to and delivers RN orientation programs

Establishes, monitors and maintains Maintains and enhances practice quality assurance and continuing fitness and competence competence requirements Participates in continuous quality improvement initiatives

Establishes and maintains professional Upholds standards and ethical codes conduct review processes to investigate and reports concerns about unsafe, allegations/complaints and concerns incompetent or unethical behaviour about RNs’ practice and implements or care disciplinary action as required

6 has its own RN professional examination.

8 || FRAMEWORK || Registration and Licensure In terms of workforce mobility, the Agreement on Internal Trade stipulates Nursing regulatory bodies establish that jurisdictional regulatory bodies rec- registration and licensure criteria for ognize those licensed professionals who RNs, in consultation with other key move between provinces and territories — provincial and territorial stakeholders. effectively eliminating them from any These stakeholders enable the regulatory labour barriers. As part of the mandate bodies to determine whether applicants to protect the public, all regulatory bodies or members are eligible to practise work collaboratively on harmonizing in their jurisdiction. Eligibility criteria registration and licensure requirements include making sure RNs entering the to support such mobility, where possible. profession have the necessary knowl- edge, judgment, attributes and skills RNs have title protection in all Canadian to provide safe, competent and ethical provinces and territories,7 which means care. They also include requirements only a registered nurse can use “RN” for demonstrating language proficiency, when signing their name (e.g., Mary Jones, good character, fitness to practise, etc. RN). Such title protections allow the public (CNA, 2007). As part of the process of to distinguish between health-care pro- determining eligibility, regulators list viders who are authorized to practise and the names of individuals who meet all those who are non-practising or retired. registration/licensing requirements in an official register. Once registered, nurses Values are held accountable to the standards, The ethical values that underpin RN limits and conditions established by their practice are expressed in standards and regulatory body. codes. One example, adopted by many Several jurisdictions have introduced regulatory bodies, is the CNA Code of their own jurisprudence component as Ethics for Registered Nurses, “a state- a registration requirement. For instance, ment of the ethical8 values of nurses and ’s “jurisprudence examination [their] commitments to persons receiving measures an individual nurse’s awareness care, [which] is intended for nurses in of provincial and regulatory policies and all… domains of nursing practice and any provincial and federal laws that would at all levels of decision-making” (CNA, relate to nursing practice in Nova Scotia” 2008b, p. 1). (College of Registered Nurses of Nova Scotia [CRNNS], 2015, para. 2).

7 In Canada, titles such as “registered nurse,” “RN” and (in some jurisdictions) “nurse” are protected (CNA, 2007) 8 In this document, the terms “moral” and “ethical” are used interchangeably based on consultations with nurse ethicists and philosophers. We acknowledge that some individuals prefer to distinguish these terms.

Framework for the Practice of Registered Nurses in Canada 9 The code identifies seven primary values registered nurses to provide safe, compe- that are central to the ethical practice tent, compassionate, and ethical nursing of RNs: care in a variety of practice settings. The competencies also serve as a guide for „ Providing safe, compassionate, curriculum development and for public competent and ethical care and employer awareness of the practice „ Promoting health and well-being expectations of entry-level registered „ Promoting and respecting informed nurses” (Canadian Council of Registered decision-making Nurse Regulators [CCRNR], 2012, p. 5). „ Preserving dignity The current competencies “reflect „ Maintaining privacy and confidentiality baccalaureate nursing education. They are client-centred, futuristic, and incor- „ Promoting justice porate new developments in society, „ Being accountable health care, nursing knowledge, and Nurses who use the CNA code of ethics nursing practice. The competencies aim bear the ethical responsibilities identified to ensure that entry-level registered under each of these primary nursing nurses are able to function in today’s values,9 which apply to their interactions realities and are well-equipped with the with individuals, families, groups, pop- knowledge and skills to adapt to changes ulations, communities and society as in health care and nursing” (CCRNR, well as those with students, colleagues 2012, p. 5). They are determined by each and other health-care professionals (See regulatory body’s ongoing evaluation Appendix A for definitions of the values). of the practice environment and further CNA updates the code of ethics regularly validated by data collected from new to ensure that it remains current with graduates and employers on required social values and conditions affecting the entry-level RN practice skills and roles. public, RNs, other health-care providers Regulatory bodies assess entry-level and the health-care system. competencies in the jurisdictions where nursing candidates have graduated10 Entry-Level Competencies by evaluating nursing education pro- Competencies refer to the knowledge, grams and the Canadian registration skills, judgment and attributes required exam. Candidates must pass this exam of an RN to practise safely and ethically to obtain a license to practise in all in a designated role and setting (CNA, Canadian provinces and territories out- 2010). “From a regulatory perspective, side Quebec, which has its own licensure the entry-level competencies serve the exam. The exams are used to measure primary purpose of nursing education the competencies needed to perform program approval by describing the safely and effectively as an entry-level competencies required for entry-level RN (CCRNR, 2014).

9 The value and responsibility statements in the code are numbered and lettered for ease of use rather than prioritization. The values are related and overlapping. 10 The specific requirements of each province and territory can be found on the regulators’ websites.

10 || FRAMEWORK || Person Health

Environment Nursing

Figure 2. Conceptual FrameworkConceptual for Organizing Framework Competencies

Professional Responsibility and Accountability Knowledge- based Practice Client Individuals Families Self- Groups Regulation Communities Populations Ethical Practice

Service to the Public

Source: Adapted from Jurisdictional Competency Process, 2012, p. 9.

Entry-level competency statements Educational Preparation are organized using a standards-based Education programs for RNs prepare conceptual framework that emphasizes students for competent, safe, com- the regulatory purposes of the five com- passionate, and ethical practice and petency categories (see Figure 2): enable them to achieve the entry-to- „ Professional responsibility and practice competencies expected of accountability new graduates. To attain all entry-level competencies, graduates must demon- „ Knowledge-based practice strate wide-ranging skills and abilities. „ Ethical practice These include cognitive, behavioural, „ Service to the public communicative and psychomotor skills, as are found, for example, in tasks „ Self-Regulation requiring manual dexterity or appropri- The examples in Appendix B show the ate responses in situations of stress or entry-level competencies’ breadth and conflict. Many provincial and territorial depth. Although presented separately, nursing jurisdictions use these requisite RNs must be able to integrate and per- skills to help prospective students and form many competencies at the same career advisors determine if nursing time to ensure safe, effective and ethical would be an appropriate career choice. practice (CCRNR, 2012).

Framework for the Practice of Registered Nurses in Canada 11 Basic nursing education in Canada In addition, learners in these programs are has moved away from acquiring entry- level competencies through diploma assisted to develop a broad knowledge programs (all provinces and territories base, and to critically reflect upon, outside Quebec that offer programs integrate and thoughtfully apply various require a baccalaureate degree). forms of knowledge in a range of health Since this shift started only in the late care settings. Learners develop abilities 1990s, both diploma-prepared and in professional reflection, self-evaluation, baccalaureate-prepared RNs currently ethical decision-making, nursing prac- practise in Canada. tice and interprofessional practice. Baccalaureate programs prepare learn- For the Canadian Association of Schools ers to identify, develop and incorporate of Nursing (CASN), a “broad based bacca- professional values that respect and laureate education is warranted given the: respond ethically and sensitively to social and cultural diversity. They foster „ increasing complexity in nursing and an understanding of the role of nursing health care; in promoting quality work environments „ rapidly expanding body of nursing that maximize patient safety. Programs and health-related knowledge; prepare students to be aware of and „ rapidly expanded use of digital tech- respond to emerging themes such as nologies in knowledge transfer and new information technologies, and utilization; global citizenship. (2011a, p.1) „ need for ‘life-long’ learning in order Research has also linked bachelor- to adapt to these changes and to educated RNs with improvements in provide a basis for advanced nursing patient safety and outcomes. An O’Brien education; Pallas et al. (2001) study of community- „ accountability to the public for safe, based health services found better competent, ethical, and effective health outcomes in people cared for nursing care; by bachelor-educated RNs. Since 2002, several studies have tied the increased „ need to understand and practice percentage of hospital RNs with bacca- nursing within the pluralistic social, laureate degrees to decreased patient cultural, and political contexts of mortality (in-hospital and 30-day mortality, Canadian society; and failure to rescue, congestive heart failure), „ diversity across Canada including: lower rates of decubitus ulcers, post- demographic, socio-economic, operative deep vein thrombosis or pul- cultural and geographic diversity” monary embolism and shorter length of (2011a, p.1). stay (Yakusheva, Lindrooth, & Weiss, 2014; CASN finds that baccalaureate programs Aiken et al., 2014; Aiken et al., 2011; Aiken, are needed to “provide the foundation for Clarke, Cheung, Sloane, & Silber, 2003; sound clinical reasoning and clinical judg- Estabrooks, Midodzi, & Cummings, 2005; ment, critical thinking, and a strong ethical Friese, Lake, Aiken, Silber, & Sochalski, comportment in nursing” (2011a, p. 1). 2008; Tourangeau et al., 2007; Van den Heede et al., 2009). And, given that better

12 || FRAMEWORK || patient outcomes mean cost savings for may include the preparation of nurses the health-care system, a strong business with advanced leadership skills in: clinical case exists for increasing the proportion practice (e.g. Nurse Practitioner, Clinical of baccalaureate-educated nurses to Nurse Specialists); nursing education 80 per cent (Yakusheva et al., 2014). (academic and healthcare institutions); administration (institutional, community In the last decade, many schools of and educational); health policy and nurs- nursing have increased the number of ing research” (Canadian Association of seats and developed additional programs Schools of Nursing, 2011b, p.1). As well, in response to Canada’s workplace needs. many nurses supplement their practice These programs, tailored to specific through studies outside of nursing (e.g., in types of prospective RN students such education or health-care administration). as internationally educated nurses, grad- uates from other university disciplines A variety of abbreviations designate the or practical nursing programs, may different levels and types of credentials that nurses may acquire. For example, „ use tools to assess prior learning and BN denotes a bachelor of nursing, BScN adapt requirements to individual needs a bachelor of science in nursing, MN (for internationally educated students); a master’s in nursing, DNP a doctor of „ offer shorter times for completion by nursing practice and PhD a doctor of recognizing non-nursing courses and philosophy. RNs may use both their delivering year-round sessions (for regulatory designation and educational second entry degree students); and qualifications after their name (e.g., „ employ bridging courses (for practical Mary Jones, RN, BScN, MN). nurse graduates). Practising RNs may also choose to pursue education at the master’s, doctoral and “Education is a powerful tool, post-doctoral levels. In terms of the skills emancipatory in fact. A nursing degree acquired through advanced degrees, “at gave me opportunities for both the Master’s level, students build upon the transformative learning at an individual knowledge and competencies acquired level and enhanced employment at at the baccalaureate level. Emphasis is a professional level. The practice of placed on developing the ability to ana- nursing requires a reflective practitioner lyze, critique, and use research and theory who is clinically competent, socially to further nursing practice. Provision is just and morally astute. All of these also made for examination of current components form the basis of a nursing issues in health care and the ethical degree. I have embraced these facets of values that influence decision-making. my education and realized that I always Core components of a Master’s cur- want more. My nursing degree was a riculum include definitive preparation motivational educational event.” designed to enable students to synthe- size research, theory and practice at an – Pertice Moffitt, RN, PhD advanced level. In addition to the core components the focus of Master’s study

Framework for the Practice of Registered Nurses in Canada 13 Scope of Practice While such controls determine the overall scope and boundaries of practice The RN scope of practice refers to the for RNs as a professional group, other activities RNs are authorized, educated factors also influence the practice of and competent to perform. Set out the individual RN. These include client in provincial/territorial legislation and needs, the practice setting, requirements regulations, the RN scope of practice is and policies of an employer and the RN’s complemented by standards, guidelines, level of competence. policy positions and ethical standards from jurisdictional nursing regulatory bodies. Many RN regulatory bodies have sought to clarify the RN scope of practice through visual diagrams (See Figure 3).

Figure 3. Scope of Practice Boundaries

Health professions or nursing legislation

Registered nurses profession regulation Professional guidelines, standards & position statements

Employer policies

Individual RN competence

Client needs

Less complex, more predictable, Highly complex, unpredictable, low risk for negative outcome(s) high risk for negative outcome(s)

Autonomous RPN or RN practice RN practice

14 || FRAMEWORK || Increasing need for RN consultation and collaboration Common ground exists between the Ontario practice guideline, RN and scopes of practice of nurses and other [Registered Practical Nurse] Practice: The health-care providers, with respect to Client, the Nurse and the Environment, Health professions or nursing legislation both their unique and shared competen- outlines expectations for nurses and cies. Mutual understanding is needed highlights the “similarities and differences Registered nurses profession in these areas to promote role clarity regulationof foundational nursing knowledge,… and ensure that each provider is utilized its impact on autonomous practice11 [and] Professional guidelines, standards properly. It is also crucial for achieving nurses’ accountabilities when collaborat- & position statements positive outcomes with clients and for ing with one another” (2014, p. 3). For establishing quality interprofessionalEmployer policiesinstance, both RNs and registered practi- collaborative teams. cal nurses can care for clients who have Individualbeen RN identified as less complex, more When deciding about nursing practicecompetence predictable and low risk for negative and staff mix issues, a number of outcomes. As shown in Figure 4, “the jurisdictions have developed tools that Client needsmore complex the care requirements, allow decision-makers to benefit from the greater the need for consultation the broadest range of health-care and/or the need for an RN to provide the professionals’ knowledge and skills. full spectrum of care” (CNO, 2014, p. 5). For instance, a College of Nurses of

Figure 4. Client Continuum

Less complex, more predictable, Highly complex, unpredictable, low risk for negative outcome(s) high risk for negative outcome(s)

Autonomous RPN or RN practice RN practice

Increasing need for RN consultation and collaboration

Source: College of Nurses of Ontario, 2014, p. 5.

11 Licensed practical nurses are not autonomous in all provinces and territories.

Framework for the Practice of Registered Nurses in Canada 15 Similarly, the distinction between the For the RN role itself, with their ability practices of RNs and licensed practical to comprehensively assess “a client’s nurses has been outlined in several status and needs, RNs use their in-depth nursing regulatory documents. These knowledge base and cognitive, critical include a joint publication by the Nurses thinking and decision-making skills ‘to Association of New Brunswick and the attend to both obvious and elusive cues, Association of New Brunswick Licensed to note minimally discernible patterns in Practical Nurses that highlights and clar- the data and to interpret and synthesize ifies some key differences between RNs information’ (CNA, 2002c). Through this and licensed practical nurses in clinical surveillance, RNs are able to recognize practice. Guidelines for Intraprofessional complications before they become more Collaboration: Registered Nurses and serious and to intervene to reduce risk Licensed Practical Nurses Working to the client and costs to the health-care Together (2015) describes the scopes of system” (CNA, 2007b, p. 18). each group and delineates the account- abilities and limits on their practices. RNs also have knowledge and skill from In addition, CRNNS and the College their baccalaureate education to partici- of Licensed Practical Nurses of Nova pate in research and evidence-informed activities. “RNs have the foundational Scotia’s Guidelines: Effective Utilization knowledge to identify practice research of [Registered Nurses] and [Licensed questions, [undertake research] and to Practical Nurses] in a Collaborative use research results to provide a scien- Practice Environment (2012) emphasizes the different values, knowledge, critical tific rationale for nursing interventions, thinking skills, etc. of RNs and licensed thereby promoting quality client care practical nurses with the aim of achiev- (CARNA, 2005; CNA, 2002c). This foun- ing a “more effective collaboration and dation also allows RNs to be ‘knowledge appropriate utilization” within that prov- navigators’ by directing clients to credi- ince’s health-care system (p. 4). ble resources, teaching them to interpret and evaluate information and helping Health experts have viewed such efforts them find their way in the health-care to define nursing roles as a way to bring system” (CNA, 2007b, p. 19). about a more cost-effective health-care system, since “working to optimal scope At the organizational level, employers of practice means achieving the most and administrators can determine effective configuration of professional which activities to assign to an RN roles as determined by other care based on the complexity of a patient’s professionals’ relative competencies” care requirements and on the need for (Nelson et al., 2014, p.22). clinical expertise and judgment, critical thinking, analysis, problem-solving, decision-making, research utilization, resource management and leadership.

16 || FRAMEWORK || A useful tool for optimizing scopes mentorship programs, advanced academic of practice is the Staff Mix Decision- education and best practice guidelines making Framework for Quality Nursing (e.g., Ontario’s Best Practice Guidelines Care developed by CNA, the Canadian program, developed by the Registered Council for Practical Nurse Regulators Nurses’ Association of Ontario [RNAO]). (CCPNR) and the Registered Psychiatric Best practice guidelines support nurses in Nurses of Canada (RPNC) (see Figure 5). moving from novices to experts (RNAO, This comprehensive, evidence-informed 2001; Grinspun, Virani, & Bajnok, 2001). resource presents a systematic approach Standards and competencies have also to staff mix decision-making for all clin- been developed for most of the national ical practice settings. “The framework nursing specialties and CASN has added outlines key client factors, staff factors, to this growing list (e.g., palliative and organizational factors and outcome indi- end-of-life care, and ). cators to be considered when assessing, planning, implementing and evaluating Continuing competence is also important staff mix decisions” (CNA, CCPNR, for strengthening the quality nursing RPNC 2012, p.7). practice and increasing public confidence in the nursing profession. All provincial The Development of Expertise and territorial nursing regulatory bodies have continuing competence programs and Continuing Competence to help RNs demonstrate how they have RNs acquire, maintain and continually maintained their competence, enhanced enhance their knowledge and skills their practice and kept their skills relevant for all aspects of their practice while and current. To be eligible to renew their ensuring the use of evidence-informed licensure/registration, RNs must meet decision-making. Both formal and continuing competence requirements informal learning can be part of an RN’s each year. Often this process includes a progression from novice to expert and reflective practice component in which an help RNs respond to changing technol- RN carries out a self-evaluation, receives ogies, systems and theories as well as peer feedback and develops, implements to specific client and career needs. and evaluates a learning plan. Promoting continuing competence is an obligation RNs develop expertise in their chosen shared by “individual nurses, professional areas of practice in several ways, including and regulatory nursing organizations, self-learning, post-RN specialty educa- employers, educational institutions and tion programs, specialty certification governments” (CNA, 2004, p. 1). (e.g., the CNA Certification Program),

Framework for the Practice of Registered Nurses in Canada 17 Figure 5. Staff Mix Decision-making Framework

Factors to consider Including but not limited to the following:

CLIENT STAFF ORGANIZATIONAL • Health-care needs • RNs, LPNs, RPNs, UCPs: • Nursing care delivery model • Acuity, complexity, predictability, – Numbers • Physical environment stability, variability, dependency – Availability • Resources and support • Type: – Education services – Individual – Competencies • Practice setting – Family – Experience • Legislation and regulations – Group • Teamwork and collaboration • Workplace health and safety – Community/population • Clinical support and consulta- • Policies • Cohort: tion • Collective agreements – Numbers • Continuity of assignment • Vision, mission and nursing – Range of conditions • Continuity of care philosophy – Fluctuations in mix • Culture • Continuity of care provider • Leadership support

Assess 5 guiding principles • Base decisions on client health needs. Plan • Base decisions on nursing care delivery model and evidence. Implement • Sustain implementation with organizational components and leadership. • Involve direct care providers and . • Make decisions with the support of information systems

Evaluate

Outcome indicators Including but not limited to the following:

CLIENT STAFF ORGANIZATIONAL • Safety/quality of care: • Quality of work-life: • Evidence-informed practice – Access to care provider – Satisfaction • Access – Morbidity – Engagement • Safety/quality of care: – Mortality – Leadership – Length of stay/service – Patient safety incidents – Professional development – Patient safety incidents – Readmissions – Optimization of scopes of – Readmissions • Quality of life, functional practice • Supervisors’ span of control independence, self-care – Evidence-informed care • Quality of work environment: management – Work relationships – Retention and recruitment • Satisfaction – Fatigue • Human resources costs: • Continuity of care • Overtime – Retention and recruitment • Continuity of care provider • Absenteeism • Case/service unit cost • Illness and injury • Turnover

18 || FRAMEWORK || Professional Conduct RN CAREERS Provincial and territorial nursing regulatory bodies are responsible for Roles and Practice Settings regulating nurses to protect the public RN practice consists of diverse yet inter- and for ensuring that the profession related domains of activity, including and its members are accountable for clinical practice, education, adminis- the delivery of safe, competent and tration, research and policy. RNs with ethical nursing care. Regulation refers positions outside of direct client-centred not only to setting standards for nursing care support those who provide it while practice, but also to enforcing them bringing leadership to the health system, by intervening on the public’s behalf collaborative practice, health care plan- when practice or professional conduct ning, and patient safety and promoting is considered unacceptable. system-wide efficiency and effectiveness. All regulatory bodies define the practices An RN’s comprehensive knowledge base, that are unacceptable or the conduct commitment to lifelong learning and deserving of sanction in accordance with their understanding of clients and the their own legislation. These definitions health system, enable them to assume are based on what are believed to be many different roles. RNs lead health-care commonly regarded as departures from teams, conduct formal research activities, established professional standards or manage nursing services, develop and rules of practice. deliver nursing education and contribute For regulators to address unprofessional to the advancement of healthy public conduct or unacceptable practice, they policy. They have the skill, expertise and must first be reported. Reporting such capacity to lead, whether in enhancing practices to regulators is the responsi- client-centred care across the care contin- bility of all stakeholders including RNs, uum, directing interprofessional teams or employers and patients. implementing new policy. Nursing leader- ship is about critical thinking, action and Nursing regulatory bodies have processes advocacy — and RNs demonstrate these in place to review serious concerns about attributes in all roles and domains of professional conduct. These processes nursing practice (CNA, 2009a). RN leader- are meant to protect the public while ship strengthens our health services and ensuring that the principles of natural health system while improving the health justice, including a nurse’s right to be and well-being of the Canadians they heard and right to be judged impartially, serve (CARNA, 2011). are respected.

Framework for the Practice of Registered Nurses in Canada 19 For many Canadians, the most familiar Health care is shifting in order to provide image of the RN is a hospital nurse, more person- and family-centred care. which is understandable given that For caregivers, such an approach involves hospitals are where 62 per cent of our collaborating with patients and families RNs currently work (CIHI, 2015). Yet RNs to deliver “respectful, compassionate, practise in a wide variety of settings, culturally responsive care that meets including the following: [clients’] needs, values, cultural back- grounds and beliefs, and preferences” „ residential care facilities (Government of Saskatchewan, 2015, „ community health centres para. 1). To support this shift to per- „ independent practices (self-employed) son-centred care, RNs are leading the development of innovative strategies „ faith communities that empower patients to improve their „ workplaces (e.g., industry, mental quality of life while bringing cost-effective health facilities) solutions to health care (CNA, 2014). „ clinics Increasingly, RNs are practising within and „ schools, colleges and universities leading interprofessional teams. As team „ clients’ homes members RNs work with other regulated health-care providers, including physicians, „ “the streets” pharmacists, physiotherapists, social „ correctional facilities workers, occupational therapists, and with „ research institutes unregulated care providers who support „ professional nursing and health-care nursing care under their direction. organizations Team-based care is particularly import- „ government agencies and ant for managing the growing rate of departments chronic disease. More than 40 per cent of Canadian adults report having “at New roles and practice settings for RNs least one of seven common conditions — are continually being added in response arthritis, cancer, emphysema or chronic to Canadians’ health needs and the obstructive pulmonary disease, diabetes, need to improve health service delivery. heart disease, high blood pressure, and RNs work with diverse client populations, mood disorders, not including depres- including Aboriginal Peoples, and in a sion” (Nasmith et al., 2010, p.13). As noted variety of contexts and practice settings. in much of the literature on the subject, They also play an increasing role in the “the role for nursing human resources is community, providing primary care in particularly clear in chronic disease man- RN-led clinics and as family practice agement in primary care, because of the nurses, community health nurses, greater requirement for patient involve- nurse prescribers, RN First Call ment and activation that is facilitated by nurses and nurse navigators. team care” (CHSRF, 2012, p. ii).

20 || FRAMEWORK || Technology is also enabling new models of 2002). Specialized practice12 within any of care delivery and advancing nursing prac- the domains (clinical, research, adminis- tice. RNs are using telehealth, electronic tration, policy, education) may relate to health records, electronic documentation, „ decision support systems and other client age (e.g., pediatrics, gerontology); technologies to optimize clinical care, „ client health problems (e.g., pain education, administration, research and management, bereavement); other health system initiatives. It is essen- „ diagnostic group (e.g., orthopaedics, tial that RNs continue to play an active role vascular surgery); in the selection, design, deployment and „ practice setting (e.g., clients’ home, evaluation of information and communica- emergency department, school, tion technology (ICT) solutions while, at government office, research the same time, be given opportunities to institution); or acquire ICT competencies to use in their practice (CNA, 2006). „ type of care (e.g., primary care, palliative care, critical care, occupa- Career Paths tional health, public health or their combinations, e.g., pediatric As outlined above, entry-level RNs are oncology). (CNA, 2008a). prepared as generalists through a broad- based baccalaureate nursing education. A number of RNs validate their compe- Each graduate is ready to practise safely, tence in a given specialty by obtaining a competently, compassionately and eth- credential that confirms their advanced ically with individuals, families, groups, knowledge and skills. Certification is one communities and populations in all stages form of credentialing offered by employ- of health and illness, at any point in the ers, educational institutions, regulatory life cycle and in any setting. bodies and CNA. The CNA Certification Program currently recognizes 20 nursing Competencies evolve and develop over specialty areas for national certification, the course of an RN’s career. As RNs and an RN who becomes CNA certified acquire and hone their skills — both in one of these areas is entitled to use a through practice and continuing pro- specialty credential(s) after their name. fessional education — they move along For instance, an RN certified in cardio- a continuum of practice from novice vascular nursing can use the CCN(C) to expert. designation (CNA, 2015). To specialize as an RN means to focus In some provinces and territories, the on one field of nursing practice or health terms “specialist,” “specialty,” “spe- care while developing knowledge and cialized practice,” “specialization” and skills in an aspect of nursing that goes “certification” have particular meanings beyond basic nursing education (Miller, for regulatory purposes.

12 The Canadian Network of Nursing Specialties represents a committed group of nurses who have joined one of 45 national asso- ciations in a specialty area of nursing.

Framework for the Practice of Registered Nurses in Canada 21 Certain career paths require additional Many RNs pursue policy and admin- registration requirements. For example, istration careers and assume formal through a combination of focused expe- leadership positions. These health-care/ rience and graduate-level education, agency organizational careers, which can some RN practices are characterized include the most senior executive posi- as advanced nursing (CNA, 2008a). In tions, exist at local, regional, provincial/ Canada, the most recognized advanced territorial and national levels. RNs who roles are the clinical nurse specialist and take up such careers often combine their the nurse practitioner. initial nursing education with a master’s degree in a non-nursing field such as in business or health administration.

My career path has taken me from my practice I often hear “you must miss volunteering in acute care and the being a real nurse,” which is a phrase I emergency department as a teenager, welcome. It creates an opportunity to working as a nurse in acute and palliative talk about what nursing is, as I work as care, co-chairing a regional nursing a nurse every day. The assessment and practice council, working as a clinical empathic listening skills I developed nurse leader and professional practice as a direct care nurse in surgery and consultant, and going back to school hospice support continue to ground for my master’s of nursing in advanced me in my practice as a nursing leader, practice leadership, to my current role as where I now influence practice changes manager for the office of the executive in a broader systems context. I draw vice-presidents, chief operating officer upon my clinical experiences daily, and chief medical officer. and I strive to continually integrate and consider patient, family and Along the way, various nurse leaders, population health perspectives when including our chief nursing officer, supporting our organization’s senior have created opportunities for me to leaders in the decision-making process. develop my skills as a nursing leader. Developing others is a responsibility I They encouraged me to use my nursing take very seriously. I’m always on the voice and participate in activities related lookout to acknowledge the potential to providing good care across the of other nursing leaders and to create continuum of health services and to opportunities to “take them with me” building strategic partnerships internal as they develop their capacity for and external to our organization — as influencing change in the complexities they supported our staff to do their best of our current health-care system. while looking after their own health. In – Christina Berlanda, RN, BSN

22 || FRAMEWORK || „ A cost-benefit analysis of school THE IMPACT OF RNS health services delivered by full-time RNs make a critical contribution to the RNs showed that society would gain health of Canadians and the health-care $2.20 for every dollar invested (Wang system. Research supports the correla- et al., 2014). tion between direct RN care and positive „ For hip-fracture patients, the odds client and system outcomes. For exam- of in-hospital mortality decreased ple, client outcomes consistently show by 0.16 for every additional full-time that RN interventions have equivalent RN per patient day (Schilling, a positive effect across a variety of Goulet, & Dougherty, 2011). health-care settings. General improve- ments include „ Increasing RN hours per patient day by 0.71 is associated with lowering the „ clinical outcomes (control or odds of an unplanned emergency room management of symptoms such visit after discharge by 45 per cent as fatigue, nausea and vomiting, (Bobay, Yakusheva, & Weiss, 2011). dyspnea and pain); „ An 8 per cent rise in direct RN patient „ functional outcomes (physical care is correlated with a 30 per cent and psychosocial functioning improvement in patient scores on and self-care abilities); caregiver responsiveness (O’Connor, „ safety outcomes (adverse incidents Ritchie, Drouin, & Covell, 2012). and complications such as pressure ulcers, falls); and „ perceptual outcomes (satisfaction with Follow any opportunities to expand or nursing care and its results). enhance your knowledge and skill set. (Doran, 2003; White, Pringle, Don’t be afraid to try something new. It’s Doran, & McGillis Hall, 2005) the opposite of pulling one thread and unravelling a sweater. Instead, you take Among specific research studies, hold of one strong thread and pick up RN direct care outcomes include others along the way to weave your own the following: career tapestry. My thread began with „ Adding one patient to a nurse’s a passion for , which workload increased the likelihood was a springboard to many other nursing that an inpatient would die within careers on land, air and sea. 30 days of admission by 7 per cent (Aiken et al., 2014). – Dorothy Latimer, RN „ Having a greater proportion of RNs relative to unlicensed assistive person- nel is associated with fewer patient falls (Patrician et al., 2011).

Framework for the Practice of Registered Nurses in Canada 23 „ RNs reduce wait times and improve RNs require resources and support to timely access by increasing the number deliver quality client-centred care and to of entry points to care, coordinating positively influence client outcomes. A care and assisting patients in navigating quality practice environment can ensure the health-care system (CNA, 2009b). the delivery of “safe, compassionate, „ As RN staffing levels go up, the risk of competent and ethical care while maxi- hospital-acquired infections and the mizing the health of clients and nurses” length of hospital stays go down (Dall, (CNA & CFNU, 2015, p. 1). Developing, Chen, Seifert, Maddox, & Hogan, 2009). supporting and maintaining quality practice environments is a responsibility „ A systematic review and meta-analysis shared by “individual [RNs], employers, of 28 international studies, by the regulatory bodies, professional associ- Agency for Healthcare Research and ations, educational institutions, unions, Quality (U.S. Dept. of Health and health services delivery and accredita- Human Services), found substantial tion organizations, governments and the evidence that increased RN staffing public” (CNA & CFNU, 2015, p. 1). leads to better patient outcomes. These outcomes include lowering patients’ odds for hospital-acquired pneumonia, hospital-related mortality RNs increase access and trust in the (in intensive care units), unplanned health system for people who may avoid extubation, respiratory failure, cardiac mainstream services through a targeted arrest and a lower risk of failure to universalism that promotes health, rescue (in surgical patients) (Kane, reduces harms and prevents illness in Shamliyan, Mueller, Duval, & Wilt, 2007). an equitable way. They create access to „ Proactive nurse-led care models a significant range of health and social focusing on patients’ preventive services for clients on the street who self-management of chronic disease otherwise wouldn’t have access. For are either more effective and equally or example, as a street nurse, I provide less costly, or equally effective and less evidence-based harm reduction services costly than standard models of care to clients in need while empowering (Browne, Birch, & Thabane, 2012). them to get involved in safe practices „ Each additional RN a hospital employs to prevent the spread of infection will save over $60,000 annually in and/or reduce harm. medical costs and improved national productivity (accounting for 72 per – Daniel Awshek, RN, BN, PHN cent of labour costs) (Dall et al., 2009). „ Increasing RN hours of care provided is associated with net cost savings through reduced length of hospital stays and avoided adverse outcomes (Needleman, Buerhaus, Stewart, Zelevinsky, & Mattke, 2006).

24 || FRAMEWORK || But the scope must also be expanded LOOKING TO appropriately to meet changed and THE FUTURE changing health needs, to encompass functions including, but not limited to, What does the future hold for prescribing, and admitting and discharg- Canada’s RNs? ing patients across all types of health The National Expert Commission (NEC) facilities” (NEC, 2012, p. 37). believes that “prevention, early iden- “It is time to test the value of a nurse-led tification, and management of chronic proactive, targeted model of compre- diseases are fundamental to controlling hensive chronic care, with a physician future health care costs as our popula- as one member of a team, where all are tion ages. Healthy aging and chronic doing what they do best and the nurse disease management both align well is enlisting all the health and social with the knowledge and practice of services that can augment the deter- nurses” (NEC, 2012, p. 12). minants of a person’s health” (Browne, Moving forward, RNs will increasingly Birch, & Thabane, 2012, p. 29).

„ lead individuals and communities in Moving forward, RNs will increasingly managing their own health; „ lead collaborative teams of health- „ care for those who are ill and play care professionals and support staff; a leadership role in helping clients „ improve access to care as an entry manage chronic diseases; point to health-promotion, disease- „ take on roles that include goal-setting, prevention and illness-care systems; monitoring, coaching, telephone „ contribute to better care by prescribing support and group education; medications and working across the „ assist clients in making their own continuum of care; decisions about their care, quality „ take a leadership role in addressing of life and health promotion at every the social determinants of health; and stage of their lives; and „ advocate for health care sustainability „ help shift health education away through improved quality, efficiency from an illness treatment model to a and effectiveness. focus on keeping people well while delivering the required care and “Canada’s nurses can and must act in support in the community. collaboration with other health profes- sionals and system leaders to ensure We believe Canada’s nurses must better health, better care and better “intensify their role as leaders of system value for all Canadians. Through their transformation, including a far-reaching sheer numbers and collective knowledge, overhaul of the ways we deploy and nurses are a mighty force for change. employ nurses. That will mean supporting Canadians expect nurses to harness and expecting every nurse to practice to that power and act” (NEC, 2012, p.1). the top of his or her scope of practice.

Framework for the Practice of Registered Nurses in Canada 25 Moving forward, RNs will increasingly Regardless of the direction health-care delivery takes in the future, RNs will play a „ exercise leadership in all areas of the crucial role within the system. History has health-care system; made it clear that the RN role is dynamic, „ take on roles as senior executives, changing in response to many influences educators, researchers and policy- both inside and outside the profession. makers in addition to direct RNs are accountable for the quality and clinical care. safety of care they deliver and for their role in shaping Canadian health care by Future RN leadership has been charac- bringing the nursing perspective to the terized by eight essential skills: health planning table. Most of all, RNs 1. “a global perspective or mindset are and will continue to be accountable, regarding healthcare and profes- ethical, competent and compassionate sional nursing issues; in each of their varied roles. 2. technology skills which facilitate mobility and portability of relation- ships, interactions and operational In the future health care must be processes; approached as a collaborative team effort with nurses working in conjunction 3. expert decision-making skills rooted with other health professionals and in empirical science; community sources to ensure the best 4. the ability to create organization care for all Canadians. cultures that permeate quality health- care and patient/worker safety; – Canadian Nursing Students’ Association 5. understanding and appropriately intervening in political processes; 6. highly developed collaborative and team building skills; 7. the ability to balance authenticity and performance expectations; and 8. being able to envision and proac- tively adapt to a healthcare system characterized by rapid change and chaos” (Huston’s “Preparing Nurse Leaders for 2020” [as cited in CNA, 2009a, p. 6]).

26 || FRAMEWORK || Glossary

Agreement on Internal Trade. An Competency. The integrated knowledge, intergovernmental agreement (1995) skills, judgment and attributes required of “to reduce and eliminate, to the extent an RN to practise safely and ethically in a possible, barriers to the free movement designated role and setting. (Attributes of persons, goods, services, and invest- include, but are not limited to, attitudes, ment within Canada and to establish values and beliefs.) an open, efficient, and stable domestic market” (Internal Trade Secretariat, Complexity. “The degree to which a n.d., para. 1). client’s condition and/or situation is characterized or influenced by a range Best practice guidelines. of variables (e.g. multiple medical diag- “Recommendations that may evolve noses, impaired decision-making ability, based on ongoing key expert expe- challenging family dynamics) (CRNBC, rience, judgment, perspective and 2011)” (CNA, CCPNR, & RPNC, 2012, p.3). continued research (Health Canada, 2008). They are also known as sys- Continuing competence program. tematically developed statements of “A program that focuses on promoting recommended practice in a specific the maintenance and acquirement of the clinical or healthy work environment competence of registered nurses through- area, are based on best evidence, and out their careers” (CNA, 2000, p. 6). are designed to provide direction to Evidence-informed decision-making. practitioners and managers in their “A continuous interactive process clinical and management decision- involving the explicit, conscientious making (Field & Lohr, 1990)” (RNAO, and judicious consideration of the best 2012, p. 7). available evidence to provide care. It Certification. Through certification, is essential to optimize outcomes for an RN demonstrates competence in individual clients, promote healthy a nursing specialty by meeting prede- communities and populations, improve termined standards established and clinical practice, achieve cost-effective confirmed by an organized, professional nursing care and ensure accountability body. Note: in some provinces, the term and transparency in decision-making within the health-care system” (CNA, certification has a particular meaning for regulatory purposes. 2010, p. 1). Client. The person, patient or resident Fitness to practise. “All the qualities who benefits from RN care. A client may and capabilities of an individual relevant be an individual, a family, group, com- to his or her capacity to practise as a munity or population. nurse, including, but not limited to, any cognitive, physical, psychological or

Framework for the Practice of Registered Nurses in Canada 27 emotional condition, or a dependence health policy and in patient and health on alcohol or drugs, that impairs his or systems management, and education her ability to practise nursing” (CRNBC, are also key nursing roles” (International 2015, p. 19). Council of Nurses, 2014, para. 1). Health. A “state of complete physical, Professional conduct review process. mental and social well-being and not A process to address allegations of merely the absence of disease or infirmity” unacceptable conduct and practice (WHO, 2006, para. 1). In March 2006, by RNs that involves investigation and the CNA board of directors resolved to (possibly) discipline and appeals. work toward including the concept of “spiritual well-being” within the WHO Staff mix. “The combination of different definition of health. categories of health-care personnel employed for the provision of direct Interprofessional collaboration. client care (McGillis Hall, 2004) in the “The process of developing and main- context of a nursing care delivery model” taining effective interprofessional working (CNA, CCPNR, RPNC, 2012, p. 3). relationships with learners, practitioners, patients/clients, families and communi- Standard. “An expected and achievable ties to enable optimal health outcomes. level of performance against which Elements of collaboration include respect, actual performance can be compared. trust, shared decision making, and part- It is the minimum level of acceptable nerships” (Canadian Interprofessional performance” (CRNBC, 2013, p. 5). Health Collaborative, 2010, p. 8). Unregulated care providers. Licensure. The legislated process “Paid health-care providers who are not through which an RN is authorized to registered with a regulatory body. They practise. Following an assessment of have no legally defined scope of prac- required competencies, a nurse may have tice, may or may not have a mandatory his or her name and other relevant infor- education requirement and do not have mation entered into the nurses’ register established standards of practice (College maintained by the regulatory body for of Registered Nurses of Manitoba, 2010). nursing in a province or territory. They ‘provide care that supports the client under the… [direct or indirect] Nursing. “Encompasses autonomous supervision of a regulated nurse’ (College and collaborative care of individuals of and Association of Registered Nurses of all ages, families, groups and commu- Alberta, College of Licensed Practical nities, sick or well and in all settings. Nurses of Alberta & College of Registered Nursing includes the promotion of Psychiatric Nurses of Alberta, 2010, p. 2) health, prevention of illness and the ‘and are accountable for their individ- care of ill, disabled and dying people. ual actions and decisions’ (College of Advocacy, promotion of a safe environ- Registered Nurses of Nova Scotia, 2004, ment, research, participation in shaping p. 10)” (CNA, CCPNR, RPNC, 2012, p. 4).

28 || FRAMEWORK || Preserving dignity. RNs recognize APPENDIX A: and respect the intrinsic worth of DEFINITIONS OF each person. VALUES IN THE CNA Promoting and respecting informed decision-making. RNs recognize, CODE OF ETHICS respect and promote a person’s right FOR REGISTERED to be informed and make decisions. Promoting health and well-being. NURSES RNs work with people to enable them to attain their highest possible level of Value health and well-being. Being accountable. RNs13 are Promoting justice. RNs uphold accountable for their actions and principles of justice by safeguarding answerable for their practice. human rights, equity and fairness and Maintaining privacy and confidentiality. by promoting the public good. RNs recognize the importance of Providing safe, compassionate, privacy and confidentiality and safeguard competent and ethical care. personal, family and community informa- RNs provide safe, compassionate, tion obtained in the context of a competent and ethical care. professional relationship.

13 The term nurse used in the code of ethics is replaced in these definitions by RN.

Framework for the Practice of Registered Nurses in Canada 29 APPENDIX B: Ethical Practice „ Demonstrates ethical responsibilities EXAMPLES OF and legal obligations related to main- taining client privacy, confidentiality REGULATORY BODY and security in all forms of communi- ENTRY-LEVEL RN cation, including social media „ Demonstrates honesty, integrity and COMPETENCY respect in all professional interactions STATEMENTS Service to the Public Professional Responsibility „ Enacts the principle that the primary and Accountability purpose of the RN is to practise in the best interest of the public and to „ Recognizes individual competence protect the public from harm within the legislated scope of practice and seeks support and assistance „ Demonstrates leadership in the as necessary coordination of health care by „ Demonstrates critical inquiry in • assigning client care; relation to new knowledge and to • delegating and evaluating the technologies that change, enhance performance of selected health- or support nursing practice care team members in carrying out delegated nursing activities; and Knowledge-based Practice • facilitating continuity of client care. „ Has a knowledge base in nursing science, social sciences, humanities and health-related research (e.g., culture, power relations, spirituality, philosophical and ethical reasoning) „ Has a knowledge base in the health sciences, including anat- omy, , pathophysiology, psychopathology, , , , genetics, immunology and

30 || FRAMEWORK || Self-Regulation „ Distinguishes between the legislated scope of practice and the RN’s individ- ual competence „ Demonstrates continuing competence and preparedness to meet regulatory requirements by • assessing one’s own practice and individual competence to identify learning needs; • developing a learning plan that uses a variety of resources (e.g., self-eval- uation and peer feedback); • seeking and using new knowledge that may enhance, support or influ- ence competence in practice; and • implementing and evaluating the effectiveness of one’s learning plan and developing future learning plans to maintain and enhance one’s competence as an RN.

Framework for the Practice of Registered Nurses in Canada 31 References Aiken, L. H., Cimiotti, J. P., Sloane, D. M., Smith, H. L., Flynn, L., & Neff, D. F. (2011). Effects of nurse staffing and on patient deaths in hospitals with different nurse work environments. Medical Care, 49, 1047-1053. doi:10.1097/ MLR.0b013e3182330b6e Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association, 290, 1617-1623. Aiken, L. H., Sloane, D. M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R.,… RN4CAST consortium. (2014). Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study. Lancet, 383, 1824-1830. doi:10.1016/S0140-6736(13)62631-8 Association of Registered Nurses of Newfoundland and Labrador. (2006). Scope of nursing practice: Definition, decision-making and delegation. St. John’s: Author. Berman, A., & Snyder, S. (2012). Kozier and Erb’s fundamentals of nursing: Concepts, process and practice (9th ed.). Toronto: Pearson. Blegen, M. A., Goode, C. J., Park, S. H., Vaughn, T., & Spetz, J. L. (2013). Baccalaureate education in nursing and patient outcomes. Journal of Nursing Administration, 43(2), 89-94. Bobay, K., Yakusheva, O., & Weiss, M. (2011). Outcomes and cost analysis of the impact of unit-level nurse staffing on post-discharge utilization.Nursing Economics, 29(2), 69-78, 87. Browne, G., Birch, S., & Thabane, L. (2012). Better care: An analysis of nursing and health system outcomes. Ottawa: Canadian Health Services Research Foundation, Canadian Nurses Association. Canadian Association of Schools of Nursing. (2011a). Baccalaureate education and baccalaureate programs [Position statement]. Ottawa: Author. Canadian Association of Schools of Nursing. (2011b). Master’s level of nursing [Position statement]. Ottawa: Author. Canadian Council of Registered Nurse Regulators. (2012). JCP entry-level registered nurse competencies. Retrieved from http://www.ccrnr.ca/assets/jcp_rn_ competencies_2012_edition.pdf Canadian Council of Registered Nurse Regulators. (2015). 2015 NCLEX RN exam. Retrieved from http://www.ccrnr.ca/index_files/CCRNRNCLEX.html

32 || FRAMEWORK || Canadian Health Services Research Foundation. (2012). Evidence synthesis for the effectiveness of interprofessional teams in primary care. Paper commissioned by the Canadian Nurses Association. Ottawa: Author. Canadian Institute for Health Information. (2015). Regulated nurses, 2014. Ottawa: Author. Canadian Interprofessional Health Collaborative. (2010). A national interprofessional competency framework. Vancouver: Author. Canadian Museum of Civilization. (2004). A brief in Canada from the establishment of New to the present. Retrieved from http://www.historymuseum.ca/cmc/exhibitions/tresors/nursing/nchis01e.shtml Canadian Nurses Association. (2000). A national framework for continuing competence programs for registered nurses. Ottawa: Author. Canadian Nurses Association. (2002). Discussion guide for the unique contribution of the registered nurse. Ottawa: Author. Canadian Nurses Association. (2004). Promoting continuing competence for registered nurses [Position statement]. Ottawa: Author. Canadian Nurses Association. (2006). Nursing information and knowledge management [Position statement]. Ottawa: Author. Canadian Nurses Association. (2007a). Canadian regulatory framework for registered nurses [Position statement]. Ottawa: Author. Canadian Nurses Association. (2007b). Framework for the practice of registered nurses in Canada. Ottawa: Author. Canadian Nurses Association. (2008a). Advanced nursing practice: A national framework. Ottawa: Author. Canadian Nurses Association. (2008b). Code of ethics for registered nurses. Ottawa: Author. Canadian Nurses Association. (2009a). Nursing leadership [Position statement]. Ottawa: Author. Canadian Nurses Association. (2009b). Registered nurses: On the front lines of wait times. Ottawa: Author. Canadian Nurses Association. (2010). Evidence-informed decision-making and nursing practice [Position statement]. Ottawa: Author Canadian Nurses Association. (2013). Social determinants of health [Position statement]. Ottawa: Author. Canadian Nurses Association. (2014). RN solutions in the care of older adults. Retrieved http://cna-aiic.ca/~/media/cna/files/en/person_and_family_care_older_adult_e.pdf

Framework for the Practice of Registered Nurses in Canada 33 Canadian Nurses Association. (2015). Cardiovascular nursing. Retrieved from http://nurseone.ca/en/certification/what-is-certification/competencies-per-specialty-area/ registered-certification-initials/cardiovascular-nursing Canadian Nurses Association, Canadian Council for Practical Nurse Regulators, Registered Psychiatric Nurses of Canada. (2012). Staff mix decision-making framework for quality nursing care. Ottawa: Authors. Canadian Nurses Association, Canadian Federation of Nurses Unions. (2015). Practice environments: Maximizing outcomes for clients, nurses and organizations [Joint position statement]. Ottawa: Authors. College of Nurses of Ontario. (2014). RN and RPN practice: The client, the nurse and the environment [Practice guideline]. Retrieved from http://www.cno.org/Global/docs/ prac/41062.pdf College and Association of Registered Nurses of Alberta. (2011). Scope of practice for registered nurses. Edmonton: Author. College of Registered Nurses of British Columbia [CRNBC]. (2013). Professional standards for registered nurses and nurse practitioners. Vancouver: Author. CRNBC. (2015). Competencies in the context of entry-level registered nurse practice in British Columbia. Vancouver: Author. College of Registered Nurses of Nova Scotia. (2015). Jurisprudence examination: The basics. Retrieved from http://www.crnns.ca/default.asp?id=190&sfield=content. id&search=6546&mn=414.1116.1128.23222.23225 College of Registered Nurses of Nova Scotia, College of Licensed Practical Nurses of Nova Scotia. (2012). Guidelines: Effective utilization of RNs and LPNs in a collaborative practice environment. Halifax: Authors. Dall, T. M., Chen, Y. J., Seifert, R. F., Maddox, P. J., & Hogan, P. F. (2009). The economic value of professional nursing. Medical Care, 47, 97-104. doi:10.1097/ MLR.0b013e3181844da8 Doran, D. M. (Ed.). (2003). Nursing-sensitive outcomes: State of the science. Sudbury, MA: Jones and Bartlett. Estabrooks, C. A., Midodzi, W. K., & Cummings, G. G. (2005), The impact of hospital nursing characteristics on 30-day mortality. , 54, 74-84. Friese, C. R., Lake, E. T., Aiken, L. H., Silber, J. H., & Sochalski, J. (2008). Hospital nurse practice environments and outcomes for surgical oncology patients. Health Services Research, 43, 1145-1163. doi:10.1111/j.1475-6773.2007.00825.x Government of Saskatchewan. (2015). Patient and family-centred care: Putting patients and families first. Retrieved from https://www.saskatchewan.ca/live/health- and-healthy-living/health-care-provider-resources/saskatchewan-health-initiatives/ patient-and-family-centred-care

34 || FRAMEWORK || Grinspun, D., Virani, T., & Bajnok, I. (2001). Nursing best practice guidelines: The RNAO (Registered Nurses’ Association of Ontario) project. Hospital Quarterly, 4(2), 54-57. Internal Trade Secretariat. (n.d.). Agreement on internal trade. Retrieved from http://www.ait-aci.ca/index_en.htm International Council of Nurses. (2014). Definition of nursing. Retrieved from www.icn.ch/definition.htm Jurisdictional Competency Process. (2012). Competencies in the context of entry-level registered nurse practice. Retrieved from the Canadian Council of Registered Nurse Regulators website: http://www.ccrnr.ca/assets/jcp_rn_competencies_2012_edition.pdf Kane, R., Shamliyan, T. A., Mueller, C., Duval, S., & Wilt, T. J. (2007). The association of registered nurse staffing levels and patient outcomes: Systematic review and meta-analysis. Medical Care, 45, 1195-1204. Kozier, B. J., Erb, G., Berman, A. T., Snyder, S., Buck, M., Yiu, L., & Stamler, L. L. (2013). Fundamentals of Canadian nursing: Concepts, process, and practice (3rd Canadian ed.). Toronto: Pearson Education Canada. Miller, J. (2002). Specialization in nursing: A background paper. Final draft submitted to the Canadian Nurses Association. Unpublished manuscript. Nasmith, L., Ballem, P., Baxter, R., Bergman, H., Colin-Thomé, D., Hebert, C.,… Zimmerman, B. (2010). Transforming care for Canadians with chronic health conditions: Put people first, expect the best, manage for results. Ottawa: Canadian Academy of Health Sciences. National Expert Commission. (2012). A nursing call to action: The health of our nation, the future of our health system. Ottawa: Canadian Nurses Association. Needleman, J., Buerhaus, P. I., Stewart, M., Zelevinsky, K., & Mattke, S. (2006). Nurse staffing in hospitals: Is there a business case for quality?Health Affairs, 25, 204-211. doi:10.1377/hlthaff.25.1.204 Nelson, S., Turnbull, J., Bainbridge, L., Caulfield, T., Hudon, G., Kendel, D.,… Sketris, I. (2014). Optimizing scopes of practice: New models for a new health care system. Ottawa: Canadian Academy of Health Sciences. Nurses Association of New Brunswick, Association of New Brunswick Licensed Practical Nurses. (2015). Guidelines for intraprofessional collaboration: Registered nurses and licensed practical nurses working together. Retrieved from http://www.nanb.nb.ca/media/ resource/NANB-GuidelinesIntraprofessionalCollaborationRNsandLPNsWorkingTogether- E-2015-10.pdf O’Brien-Pallas, L. L., Doran, D. I., Murray, M., Cockerill, R., Sidani, S., Laurie-Shaw, B., & Lochhass-Gerlach, J. (2001). Evaluation of a client care delivery model, part 1: Variability in nursing utilization in community home nursing. Nursing Economics, 19, 267-276.

Framework for the Practice of Registered Nurses in Canada 35 O’Brien-Pallas, L. L., Doran, D. I., Murray, M., Cockerill, R., Sidani, S., Laurie-Shaw, B., & Lochhass-Gerlach, J. (2002). Evaluation of a client care delivery model, part 2: Variability in client outcomes in community home nursing. Nursing Economics, 20, 13-21, 36. O’Connor, P., Ritchie, J., Drouin, S., & Covell, C. L. (2012). Redesigning the work- place for 21st century healthcare. Healthcare Quarterly, 15, 30-35. doi:10.12927/ hcq.2012.22844 Ordre des infirmières et infirmiers du Québec. (2010).Outlook on the practice of nursing. Retrieved from https://www.oiiq.org/sites/default/files/264NS_doc.pdf Patrician, P. A., Loan, L., McCarthy, M., Fridman, M., Donaldson, N., Bingham, M., & Brosch, L. R. (2011). The association of shift-level nurse staffing with adverse patient events. Journal of Nursing Administration, 41(2), 64-70. doi:10.1097/ NNA.0b013e31820594bf Registered Nurses’ Association of Ontario. (2012). Toolkit: Implementation of best practice guidelines (2nd ed.). Toronto: Author. Schilling, P., Goulet, J. A., & Dougherty, P. (2011). Do higher hospital-wide nurse staffing levels reduce in-hospital mortality in elderly patients with hip fractures?: A pilot study. Clinical Orthopedics and Related Research, 469, 2932-2940. doi:10.1007/s11999-011-1917-8 Tourangeau, A. E., Doran. D. M., McGillis Hall, L., O’Brien Pallas, L., Pringle, D., Tu, J. V., & Cranley, L. A. (2007). Impact of hospital nursing care on 30-day mortality for acute medical patients. Journal of Advanced Nursing, 57, 32-44. doi:10.1111/j.1365-2648.2006.04084.x Van den Heede K., Lesaffre E., Diya L., Vleugels, A., Clarke, S. P., Aiken, L. H., & Sermeus, W. (2009). The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level: Analysis of administrative data. International Journal of Nursing Studies, 46, 796-803. doi:10.1016/j.ijnurstu.2008.12.018 Wang, L. Y., Vernon-Smiley, M., Gapinski, M. A., Desisto, M., Maughan, E., & Sheetz, A. (2014). Cost-benefit study of services.JAMA Pediatrics, 168, 642-648. doi:10.1001/jamapediatrics.2013.5441 White, P., Pringle, D., Doran, D., & McGillis Hall, L. (2005). The nursing and health outcomes project. Canadian Nurse, 101(9), 15-18. World Health Organization. (2006). Constitution of the World Health Organization (45th ed. Suppl.). Retrieved from http://www.who.int/governance/eb/ who_constitution_en.pdf Yakusheva, O., Lindrooth, R., & Weiss, M. (2014). Economic evaluation of the 80% baccalaureate nurse workforce recommendation: A patient-level analysis. Medical Care, 52, 864-869.

36 || FRAMEWORK ||

N