Week 6 lecture/ Required Readings

Health Professionals & Interprofessional Collaboration (NURS 3001 B Week 6)

Agenda

  • Online Class via Zoom: Link provided on eClass.

  • Topics for Discussion:

    • Scholarly Paper and Group Presentations.

    • Roles and Structures: Regulated Nursing in Canada.

    • Interprofessional Collaboration.

    • Delivery of Care and Practice Settings.

    • Control Acts and Delegated Acts.

    • Interprofessional Education.

Who Delivers Health Care?

  • Who delivers health care and where it is delivered are undergoing continual change

  • Health care in Canada is provided by a wide variety of healthcare providers:

    • Conventional (or mainstream) medical practitioners

    • Those who practice complementary and alternative medicine

    • Informal workers:

      • Volunteers of community organizations

      • Friends and family members

Roles and Structures: Regulated Nursing in Canada

  • Four Designations in Nursing:

    1. Registered/Licensed Practical Nurse (RPN/LPN)

    2. Registered Psychiatric Nurse (RPN)

    3. Registered Nurse (RN)

    4. Nurse Practitioners or Registered Nurse, Extended Class (NP/RN(EC)) in Ontario.

  • Importance of Role Clarity:

    • Need for better role clarity and addressing historical power structures that impeded interprofessional and intraprofessional collaboration

Registered/Licensed Practical Nurses (RPN/LPN)

  • Registered Practical Nurses in Ontario (rest is LPN)

  • Make up 29% of regulated nursing workforce

  • Role first established in late 1930s

  • Manitoba was first to require registration in 1946

  • Education – Diploma

  • Registration Examination – Canadian Practical Nurses Registration Examination (except Quebec); in 2022 Ontario and BC will move to Regulatory Exam – Practical Nurse Jurisprudence – required in Alberta, Manitoba, Ontario, NB, NS

Registered Psychiatric Nurses (RPN)

  • Exclusive to Manitoba, Saskatchewan, Alberta, BC, and Yukon, comprising 1.4% of the workforce.

  • First established during WWII (early 1940s).

  • Registration Context:

    • Saskatchewan was the first to require registration in 1948.

    • Education options include Baccalaureate or Diploma.

    • Examination: Registered Psychiatric Nurses of Canada Examination (if in Yukon, must go to other provinces for examination).

    • No Jurisprudence requirement.

Registered Nurses (RN)

  • In all provinces and territories

  • Represent 68% of the regulated nursing workforce

  • Historical Role:

    • Indigenous healers were the first nurses in Canada

    • Registration requirement began in Manitoba (1913).

  • Education:

    • Typically requires a Baccalaureate, with variations in Quebec (Quebec – has both BScN and Diploma).

  • Examination:

    • NCLEX, except in Quebec.

    • Jurisprudence in multiple provinces- BC, Alberta, Ontario, NB, NS, PEI.

Nurse Practitioners/ Registered Nurse, Extended Class RNs

  • In all provinces and territories

  • Account for 1.4% of the regulated nursing workforce.

  • Historical Context:

    • Expanded roles emerged in the 1890s in northern and remote communities.

    • Ontario and BC legislated NP authority and scope of practice in 1997.

  • Educational Requirements:

    • Generally a Master's degree.

    • Registration Examinations: Include Primary Health Care, Pediatrics, and Adult (Except Quebec).

    • Jurisprudence presented in Ontario and NS.

Interprofessional Collaboration

  • Key Aspects:

    • Socialization

    • Role Clarification.

    • Access to prevention, promotion, and management.

    • Ensuring the right provider meets patient needs at the right time and place.

    • Focus on Patient Safety.

    • Respecting diverse knowledge, skills, and perspectives.

    • Identifying appropriateness

    • Support patient care needs

Intra-professional vs Interprofessional

  • Intra-professional: Collaboration among nurses only.

  • Interprofessional: Involves multiple healthcare providers.

  • Interdisciplinary: Across disciplines- Includes non-healthcare professionals (e.g., sociology, engineering, IT, law).

Practice Settings

  • Where care is provided includes:

    • Hospitals.

    • Residential care facilities.

    • Rehabilitation centers.

    • Community care facilities.

    • Hospices

    • Clinics and Offices

    • Primary care settings.

    • Home care

Trends in Health Care Delivery

  • In 2014, Statistics Canada reported that 4.5 million Canadians did not have a family physician

  • To address the issue, all regions are experimenting with different ways to deliver primary care:

    • Patient's Medical Home (PMH).

    • Interprofessional collaboration.

    • Community-based care.

Categories of Health Care Providers

  • Conventional Health Care Providers: Physicians, nurse practitioners, midwives, nurses, and dentists.

  • Allied Health Professionals: Dental hygienists, dietitians, optometrists, psychologists.

  • Complementary and Alternative Practitioners: Indigenous healers, naturopathic doctors, massage therapists.

Conventional Medicine

  • Conventional medicine is frequently referred to as orthodox, mainstream, traditional, or Western medicine.

  • Conventional healthcare practitioners diagnose health problems; treat pre-diagnosed health problems; and render technical, therapeutic, or supportive care with scientifically proven therapies, medication, and surgery.

Alternative Medicine

  • Critics of alternative medicine believe that treatments should be scientifically proven before they are used (also called an evidence-informed or evidence-based approach).

  • A significant number of Canadians use CAM at some point in their lives. This may be due to many factors, including:

    • disillusionment with conventional treatment

    • difficulty getting appointments with their doctor

    • cultural influences and belief systems that contradict mainstream medicine

    • information available on the Internet

    • many more people are actively participating in their own health care and treatment options.

Regulation of Health Care Professions

  • Educational standards

  • Provincial and territorial examinations

  • Practitioner’s scope of practice, which outlines skills, acts, and services the practitioner is able to perform competently and safely

  • Curbing of individual’s practice if standards are not met

  • Formal complaints process for the public

  • Complaints investigation and follow-up

  • Title protection

  • Competence and quality assurance

Performing Controlled Acts

  • Controlled acts, if not performed by a qualified practitioner, may result in harm to a patient

  • Controlled acts are identified by the Regulated Health Professions Act (RHA) or the equivalent in each jurisdiction

  • Examples of controlled acts include:

    • Giving an injection

    • Setting or casting a fracture

    • Passing a nasogastric tube

    • Prescribing a medication

Exceptions to Controlled Acts

  • Most provinces and territories allow controlled acts to be performed by competent yet unregulated individuals, including

    • A person with appropriate training providing first aid or assistance in an emergency

    • Students learning to perform an act under the supervision of a qualified person

    • A person, such as a caregiver, trained to perform an act (e.g., giving injections to a person with diabetes)

    • An appropriate person designated to perform an act in accordance with a religion

Delegated Acts

  • Definition: A delegated act by definition is the means by which a regulated health professional (authorized to perform the delegated act)transfers legal authority or permits another person to carry out a controlled act they are otherwise unauthorized to do (procedures that are not controlled acts do not require delegation)

  • Although guidelines and protocols for delegation of medical acts vary across Canada, in general the delegated act must be clearly defined and supervised accordingly

  • The delegating health care professional, the delegate, the facility, or environment in which the act is performed share responsibility for the act

Nonregulated Professions and Occupations

  • People who work within nonregulated occupations do not have federal or provincial legislations governing their occupations.

  • Like regulated professions, many nonregulated occupations have professional organizations or bodies that award certification when a person completes a set of written or practical examinations or both

Definitions in Interprofessional Collaboration

  • Interprofessional: The relationship between various professions as they purposely interact to work and learn together to achieve a common goal. For example, if a patient has trouble swallowing, nurses, speech language pathologists and dietitians need to work together as a team to figure out what is wrong and how to help the patient.

  • Collaboration:

    • Involves multiple people interacting to achieve a common goal

    • Consists of social inputs and task inputs

    • An active and ongoing partnership between professionals and institutions with diverse backgrounds and mandates who work together to provide services

    • A process that involves cooperation, communication, negotiation, trust, respect, and understanding to build a synergistic alliance that maximizes the contributions of each participant

Critical Elements of Collaboration

  1. Coordination (working to achieve shared goals)

  2. Cooperation (contributing to the team, understanding and valuing the contributions of other team members)

  3. Shared decision-making (relying on negotiation, communication, openness, trust, and a respectful power balance)

  4. Partnerships (open, respectful relationships cultivated over time in which all members work equitably together)

Interprofessional Collaborative Practice: Definition

  • An interprofessional process of communication and decision-making that enables the separate and shared knowledge and skills of care providers to synergistically influence the client/ patient care provided.

Interprofessional Education

  • Occasions when two or more professions learn with, from and about each other to improve collaboration and the quality of care.

  • CIHC uses the term to include all such learning in academic and work based settings before and after qualification, adopting an inclusive view of "professional".

Evidence of Interprofessional Collaborative Practice

CHSRF Synthesis 2007: Overall Key Messages

  • High quality evidence supporting positive outcomes for patients/clients, providers& system in specialized areas (e.g. diabetes, mental health, hypertension) with interprofessional collaboration e.g

    • Physician/ pharmacist mgmt. hypertension with significant B/P reduction

    • Diabetes shared care very positive feedback re service & increased confidence providing routine diabetes care in practice

    • Case manager & PC physician collaboration for depression significant positive effects in standardized depression outcomes

Positive Outcomes for patients/clients, providers and system when interprofessional collaboration fostered and supported on basis of servicing geographic populations or population health models (environmental scan/ some of literature reviews) e.g.":

  • FP physicians and clinical dieticians resulted in significant decrease in weight (50% with intense follow up and personal diet)

  • Some correlation (statistically significant) in team effectiveness and lower wait time appts./few ER visits/ higher access PHC

  • Interprofessional services to population 15,000 with improvement satisfaction professional practice, reduction in ER use, healthier lifestyles.

Regulatory and legislative support not readily evident to foster and promote consistency and clarity of interprofessional collaborative partnerships and scope of practice, nor availability of physician (and other professional) remuneration models

Evidence for interprofessional practice:

  • Canadians who have additional access to either nurse and/ or other professional were:

    • > 2.5 times more likely to report range of services that met needs

    • 42% more likely to rate quality health care as good, very good, or excellent.

    • 46% more likely to have more knowledge of conditions

    • 67% more likely to report know- how re preventing future problems

Conclusion

  • Evidence to support interprofessional practice (especially for management chronic disease)

  • Some evidence & lot of support for interprofessional practice

  • Need to clarify understanding/ definitions re interprofessional practice & education

  • Need for one set of interprofessional competencies for all professions

  • Better evaluation/ research needed

Questions for Reflection

  • What is the current status of Interprofessional Education?

  • How well does current Interprofessional Education support Interprofessional Practice?