A Systematic Approach to Maximizing Nursing Scopes of Practice

Key Implications for Decision Makers

  • Regulatory bodies must work together to harmonize existing competency frameworks and consult with each other in the future development of their respective regulatory documents. Regulatory bodies and unions representing the three categories of nurses must work together to help their respective members become more informed about their own and their colleagues' roles in the health system.
  • Policy makers must address the role ambiguity that currently exists across the health professions. A clear understanding of professional roles and contributions is essential to appropriate health human resources planning, including planning for the right number and type of education seats.
  • Employers and managers must engage health professionals in discussion of distinct and shared responsibilities among team members to promote effective collaborative practice, improve role clarity, and enhance quality of care. Continuing education of the current workforce will be an important strategy in moving toward more effective teamwork in healthcare.
  • Educators have an important role to play in preparing future health professionals for collaborative practice. It will require they have, and are able to transmit, accurate knowledge to their students about the roles and responsibilities of nurses and other providers in the health system.
  • Employers, regulatory bodies, educators, practitioners, unions, and policy makers must engage in dialogue about strategies for improving the utilization of all health professionals. Employers and managers must employ effective change management strategies when introducing new staff mix models.
  • Healthcare organizations, policy makers, and agencies responsible for monitoring and reporting on health system performance must collaborate in addressing the current inadequacy of databases that allow linkage of unit or program level staff mix and contextual data to patient, provider, and system outcomes.

Executive Summary

The term "scope of practice" has been widely used in a number of recent healthcare reports 1, 2, 3 and professional documents. 4, 22 It is seldom clearly defined, although a thorough understanding of the concept is obviously essential to effective utilization of the health workforce. In this study of nursing scopes of practice, differentiation was made between nursing roles (pre-defined expectations of nurses' contribution based on professional education and role) and role enactment (actual practice as delimited by legislation, employer policies, experience, context of practice, etc.).

The primary purpose in this study was to elicit nurses' (licensed practical nurses, registered nurses, and registered psychiatric nurses) perceptions of the extent to which they are able to work to full scope and to identify perceived barriers and facilitators to optimizing their roles. Literature searches conducted prior to the study revealed no consistent use of the term, and it was therefore considered important to understand how nurses themselves describe what it means to work to full scope and what strategies they recommend that will enable them to be better utilized. Other members of the healthcare team were also interviewed to elicit their perceptions of nurses' roles and of similarities and differences between their roles and those of nurses.

The study was conducted in three health regions - Calgary Health Region and Capital Health in Alberta , and Saskatoon Health Region in Saskatchewan . Patient health needs and the practice environment are known to significantly influence role enactment. 4, 22 Considerable efforts were thus made to collect descriptive data about population and contextual factors across the three sites, to examine their effect on descriptions of scope enactment, and to assess the practicality of collecting outcome data relevant to measurement of the impact of work redesign in subsequent research.

Quantitative data collection for this study proved to be a considerable challenge. Measuring the impact of staff mix changes or of changes in interprofessional roles requires the availability of patient and provider data at a unit or program level, where most staffing decisions are made. The difficulties encountered in achieving data comparability across the three sites on a number of the variables selected for this study highlighted substantial deficits in the databases currently available to inform unit or program level measurement of the impact of current and emerging models of collaborative practice on provider, patient, and system outcomes.

More importantly, this research revealed substantial role confusion within nursing and between nursing and other professional groups employed in acute care settings. Further, it appears that role clarification and redesign of the work of health professionals, certainly within acute care but most likely across all care delivery settings, might well provide an opportunity to mitigate some of the workload pressures that are inhibiting professionals from working to their full scope of practice.

Clarifying roles will require a strong commitment to interprofessional and cross-sector (that is, practice, education, unions, regulatory bodies, and policy makers) collaboration in redefining the "unique" and "shared" contributions of each professional group, recognizing that substantial overlap exists in many of the activities they perform. Staff-mix decision-making for a specific unit, program, or setting and effective long-term health human resources planning are difficult to achieve if based simply on a review of the "competencies" or clinical skills shared among so many health professionals. In this research, nursing practice tended to be described more often on the basis of "functional tasks" than "functional roles." The distinct differences that exist in the education, knowledge, and skill base of the three regulated nursing groups should distinguish the roles they are expected to perform in providing nursing care. Those differences were not clearly articulated by participants in this study.

Health human resources planning should begin with an assessment of the most appropriate type of provider needed to carry out particular roles, given the current and emerging needs of the population and predicted changes that will occur in healthcare and in the external environment influencing healthcare delivery. The question that must be asked is not "who can perform this set of tasks or activities?" but rather "who should and why?" given the context and population.

It would appear that role clarification should begin with examining commonalities and differences in the education of health professionals and determining the relevance of that education to employers responsible for appropriate utilization of health professionals and policy makers who fund the delivery of healthcare. Ultimately, the focus must be on ensuring that we prepare the right number and type of health professionals needed to meet emerging population health needs and achieve intended patient, provider, and system outcomes.