A Discussion Paper on Scope
of Nursing Practice for
Registered Nurses in
Nova Scotia
2009
©2005. College of Registered Nurses of Nova Scotia
revised 2009
4005-7071 Bayers Rd, Halifax, NS B3L 2C2
All rights reserved. Copies of A Discussion Paper on Scope of Nursing Practice for Registered Nurses in
Nova Scotia can be obtained by contacting the College of Registered Nurses of Nova Scotia at 491-9744, ext. 230
(toll-free in NS 1-800-565-9744). This document can also be downloaded from the College website at www.crnns.ca.
Table of Contents
Introduction ................................................................................................................................................. 4
Health Human Resource Planning .............................................................................................................. 6
Framework to Analyze Scope of Practice ................................................................................................... 8
The Profession’s Scope of Practice......................................................................................................... 8
Principles and Criteria........................................................................................................................... 10
Individual Scope of Practice ................................................................................................................. 12
Full Scope of Practice ........................................................................................................................... 13
Components of Scope of Practice for Registered Nurses ......................................................................... 14
Nursing Process .................................................................................................................................... 14
Assessment ........................................................................................................................................ 15
Planning ............................................................................................................................................ 17
Implementation ................................................................................................................................. 18
Evaluation ......................................................................................................................................... 19
Professional Nursing Relationships ...................................................................................................... 20
Leadership ............................................................................................................................................. 23
Teaching and Learning ......................................................................................................................... 24
Summary ................................................................................................................................................... 26
Appendix: Diagram - Full Scope of Practice of the Registered Nurse ..................................................... 27
Reference List ........................................................................................................................................... 29
Bibliography ............................................................................................................................................. 31
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
3
Introduction
This discussion paper sets the foundation for future work that will enable registered nurses to more fully
interpret their individual scope of practice, as it fits within the broad definition for the profession in
Nova Scotia. This paper begins by providing a brief overview of health human resource planning at both
the national and provincial levels. It also includes the broad definition of the practice of nursing found in
the Registered Nurses Act (RN Act, 2006), introduces the principles and criteria that can be considered
when determining the scope of practice of a healthcare provider, and identifies factors that affect the
individual scope of practice of registered nurses. With this information, registered nurses and employers
will have a greater understanding of how the role of the registered nurse fits in healthcare delivery and
effectively contributes to decision-making in determining the skill mix required to meet the health needs
of the population they serve. The information in this paper will also provide consumers of nursing
services with a general understanding of scope of practice, to better understand who is qualified to
provide different kinds of services (Canadian Nurses Association, 1993).
Health reform has challenged registered nurses to not only think differently about how health care is
delivered but to also work differently. Over the past decade, registered nurses have steadily moved from
a hospital-based model of care towards a community based model and the provision of non-traditional
services (Canadian Nurses Association, 2003a). In trying to meet healthcare demands, registered nurses
have a responsibility to more critically analyze the role they play in the healthcare system.
Changes in healthcare delivery over the past decade have prompted a redesign of the way nurses provide
care. Some registered nurses perceive that the role of the RN is being eroded, generating concern that
some aspects of their role are being given away or absorbed by other healthcare providers or passed onto
family members in a community setting. Registered nurses often wonder what is left of their role and, in
some healthcare settings, question if there will be a role in the future. Determining the full scope of
practice of individual registered nurses will answer these concerns and also lead to new, innovative and
more effective ways to deliver health care to clients.
The continuous change and evolution of the healthcare system, although necessary, contributes to
instability in the workforce. Working conditions are difficult, care is fragmented, and the work climate is
strained; all factors that force registered nurses to make choices (e.g., to leave the workplace, the
province, the country or, regrettably, the profession). Registered nurses choosing to remain within the
workforce in Nova Scotia will have an opportunity to be involved in implementing some of the
recommendations of the final report of the Canadian Nursing Advisory Committee and to contribute to
more positive practice environments. No matter what the choices change in the healthcare system is
inevitable in order to best meet population health needs now and in the future (Canadian Nurses
Advisory Committee, 2002).
Health human resource planning in Canada is being redesigned in order to be more responsive to a
changing healthcare system. Activities are outcome oriented and driven by population health needs not
just the demand for services, and will ensure that the healthcare system is efficient and effective
(Tomblin Murphy, O’Brien-Pallis, 2002). Therefore, it is essential that registered nurses be forward
thinking in planning for the future, to better meet the health needs of the population. Results of these
changes may not be immediate as effort and cost must be invested up front, and programs must be
implemented and evaluated before positive outcomes can be measured. Having all healthcare providers
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
4
working to their full scope of practice is pivotal to meeting population health needs and determining the
best staff-mix in particular healthcare settings. The onus is on registered nurses to recognize what is
nursing and what is not …clarifying their scope of nursing practice within the broad definition described
in the RN Act. The result may be the easing of tensions that are becoming evident as all healthcare
providers examine their professional roles (Tomblin Murphy, O’Brien-Pallis, 2002).
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
5
Health Human Resource Planning
In Nova Scotia, as in the rest of Canada, registered nurses are experiencing pressures, mostly from
within the profession, to re-examine the role of registered nurses within a continually changing
healthcare system. In 1993, the Canadian Nurses Association examined scope of practice for the
registered nurse and many of the findings are still relevant today. Registered nurses, as well as other
healthcare professionals, recognize that interpreting their scopes of practice is one way of contributing to
a more sustainable health workforce while, at the same time, noting it is one of the key challenges that
faces the current Canadian healthcare system (Canadian Nurses Association [Joint Position Paper],
2003).
A recent collaboration by the Canadian Medical Association (CMA), the Canadian Nurses Association
(CNA), and the Canadian Pharmacists Association (CPhA) resulted in a joint position paper on Scopes
of Practice (2003). These groups agree on the principles and criteria that can be used to determine
scopes of practice and that determining scopes of practice allows health care professionals to better meet
the healthcare needs of Canadians by serving the interests of patients safely, efficiently, and
competently. It is their position, and the College of Registered Nurses of Nova Scotia agrees, that any
policy decisions related to scope of practice should: 1) put clients* first; 2) be grounded in principles
that reflect a commitment to professionalism; 3) include lifelong learning and patient safety; and 4)
recognize the need for legislative and regulatory changes to support evolving scopes of practice.
The Health Human Resources Plan (HHRP) introduced by Tomblin Murphy and O’Brien-Pallis (2002)
is currently being designed based on a population health needs model. Their conceptual framework
reflects the complexity of the processes underlying both the needs for population health and the delivery
of services. They also consider the effects of the HHRP on population, provider and system outcomes.
The HHRP is based on comprehensive information that points to the required number of relevant
healthcare providers who can work together in ways that can maximize health outcomes (Tomblin
Murphy, O’Brien-Pallis, 2002). In order to contribute to this plan in a meaningful way, to move one step
closer towards building a workforce designed to meet the health needs of Nova Scotians, registered
nurses need to clearly determine their scope of practice.
However, a national health human resources plan cannot be isolated from the broader system within
which healthcare services are provided. The discussion paper by Murphy and O’Brien-Pallis analyses
how current health human resource policies and practices might inhibit change for the future. For
instance, they found a recurring theme is to build a workforce that is designed to meet the health needs
of communities. To do this healthcare providers must be prepared to work on complex teams, be
educated for teamwork, and have an increased focus on planning and delivering education programs
based on the health needs of the population. One option would be to redesign the current work
environment for all health professionals, where each professional would work to the fullest scope of
practice. The authors contend that there is no unambiguous right number and mix of health
professionals, but rather that health provider requirements must be determined by “broad societal
decisions about the level of commitment of resources to health care, organization of the delivery and
funding of health care programs, and the level and mix of health care services provided” (Tomblin
Murphy, O’Brien-Pallis, 2002, p. vi).
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
6
The results of a provincial study in Nova Scotia support the idea of a national health human resources
plan. A Study of Health Human Resources in Nova Scotia (2003) distributed by the Health Care Human
Resource Sector Council acknowledges that the healthcare environment is changing. One of the changes
proposed is to focus on wellness and place a greater emphasis on the determinants of health. Another
change is that healthcare delivery continue to move in the direction of an integrated community-based
approach that focuses on a team-based, shared care model of service delivery. As Nova Scotia moves
ahead with primary healthcare reform, all healthcare providers are encouraged to re-examine their
scopes of practice, adapt to changing roles, and acquire the competencies necessary for a new system of
service delivery. To prepare for this the report suggests that health providers not only have to anticipate
change in work routines but also in relationships with other health providers. An understanding of team
behaviours is suggested, as well as continuing to form partnerships with family, community members or
complimentary providers (Health Care Human Resource Sector Council, 2003).
Clearly, registered nurses in Nova Scotia are well positioned to contribute to these plans at both the
national and provincial level. If it is critical that the right providers work with Canadians to meet their
health needs, then the question that must be consistently asked is if the right (appropriately educated)
healthcare providers are working in the right locations to meet the health needs of the population
(Tomblin Murphy, O’Brien-Pallis, 2002). In trying to find the appropriate balance between institutional
and community based care, health professions, governments, and regulatory bodies must take
responsibility to ensure that the right service is provided at the right time, in the right place by the most
appropriate mix of healthcare providers to meet the population’s health care needs (Canadian Nurses
Association, 1993).
It is recognized that all healthcare professionals need to practise to their fullest capacity within their
scope of practice and, at the same time, realize that though roles may be unique, scopes of practice can
often overlap (Tomblin Murphy, O’Brien-Pallis, 2002).
(*Client is defined as the recipient of nursing services: e.g., individual, family, guardian, groups, population or
entire communities.)
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
7
Framework to Analyze Scope of Practice
The following sections of this discussion paper outline a framework that could be utilized when
examining the individual scope of practice of registered nurses. The first section discusses the broad
legislative interpretation of scope of practice for registered nurses in Nova Scotia. The second section
identifies general principles and criteria that apply to any healthcare provider when examining scope of
practice. And the third section identifies factors that influence registered nurses when defining their
actual or individual scope of practice. (See Appendix for a schematic model of this framework.)
The Profession’s Scope of Practice
The parameters of practice are affected by many variables; therefore, determining the scope of nursing
practice is a dynamic, yet complex process. To accommodate new nursing functions that are evolving as
a result of new knowledge and/or improved technology it is recommended to adopt a broad definition of
the scope of practice. According to a number of sources, a broader definition of the scope of practice of
registered nurses lends itself to maximizing the scope of practice (College of Registered Nurses of
Manitoba, 1999; Health Authorities Health Professions Act, Regulations Review Committee, 2002;
Davies, Fox-Young, 2000).
In the current nursing literature many authors agree that a profession’s scope of practice encompasses
the activities that its members are authorized and educated to perform. The overall scope of practice for
that profession sets the outer limits of practice for all members, at the same time retaining flexibility so
that establishing rigid boundaries does not threaten the ability of the profession to grow and develop
(Lillibridge, Axford, and Rowley, 2000). The scope of nursing practice in Nova Scotia includes the core
of the nursing process, as stated in the RN Act, as well as the requirement of specialized skills, expert
knowledge and professional judgment or, in other words, competency to manage complex care.
In Nova Scotia, a broad definition of scope of practice is defined by legislation in the RN Act: "practice
of nursing" means the application of specialized and evidence-based knowledge of nursing theory,
health and human sciences, inclusive of principles of primary health care, in the provision of
professional services to a broad array of clients ranging from stable or predictable to unstable or
unpredictable, and includes
(i) assessing the client to establish the client's state of health and wellness,
(ii) identifying the nursing diagnosis based on the client assessment and analysis of all relevant
data and information,
(iii) developing and implementing the nursing component of the client's plan of care,
(iv) co-ordinating client care in collaboration with other health care disciplines,
(v) monitoring and adjusting the plan of care based on client responses,
(vi) evaluating the client's outcomes,
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
8
(vii) such other roles, functions and accountabilities within the scope of practice of the
profession that support client safety and quality care, in order to
(A) promote, maintain or restore health,
(B) prevent illness and disease,
(C) manage acute illness,
(D) manage chronic disease,
(E) provide palliative care,
(F) provide rehabilitative care,
(G) provide guidance and counselling, and
(H) make referrals to other health care providers and community resources,
and also includes research, education, consultation, management, administration, regulation,
policy or system development relevant to subclauses (i) to (vii); (RN Act, 2006)
This broad definition of nursing identifies the activities that can be performed only by registered nurses
because there may be significant risks to the public if individuals lacking the necessary skills and
knowledge perform them. This definition, including the reference to “specialized and evidence-based
knowledge of nursing theory”, establishes the basis for the scope of practice in which registered nurses
may engage and helps clarify what nursing practice is relative to the practice of other healthcare
disciplines. Utilization of nursing theory is the basis for the performance of functions as stated in the
definition of nursing practice (Canadian Nurses Association, 1993).
In a College document entitled Delegation Guidelines for Registered Nurses (2003), a more succinct, yet
still broad, definition states: “the scope of practice of the nursing profession consists of the roles,
functions and accountabilities which members of the nursing profession are educated and authorized to
perform”.
In the past, some professional nursing bodies tried to interpret broad definitions by listing tasks and
procedures performed by registered nurses. However, while these broad definitions do not provide
specific direction in terms of the scope of practice of individual registered nurses, there is now
agreement that the boundary of nursing practice cannot be determined by simply listing tasks that are
quickly outdated and often incomplete outside of the domain of clinical practice. Nursing practice is, in
fact, far too complex to be reduced to lists of tasks and procedures (Canadian Nurses Association, 1993).
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
9
Principles and Criteria
According to the joint position paper on scopes of practice prepared by CNA, the Canadian Medical
Association and the Canadian Pharmacists Association, the following principles and criteria were
recommended to used in determining scopes of practice:
Principles
According to the joint position paper, all healthcare providers should assess their scope of practice based
on the following principles:
Focus on the needs of the population served to promote safe, ethical, high quality care that is
timely, affordable, and provided by competent healthcare providers.
Flexibility is an approach that is responsive to the needs of the population and enables
providers to practise to the extent of their education, experience and competency.
Collaboration and cooperation supports interdisciplinary approaches to health care and
good health outcomes. An evidence-based approach and good communication are essential.
Coordination of individual patient care is the role of a qualified healthcare provider.
Patient choice of healthcare provider should be taken into account.
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
10
Criteria
Criteria are identified as the principles or standards by which something is judged. The joint position
paper on Scopes of Practice (2003) recommends that healthcare providers consider using the following
criteria when determining scopes of practice:
Accountability: The degree of accountability, responsibility and authority that the healthcare
provider assumes for the outcome of her/his practice.
Education: The breadth, depth and relevance of the healthcare provider’s education program,
taking into consideration provider certification and maintenance of competency.
Competency and standards of practice: The degree of knowledge, values, attitudes and skills
of the provider group. Take into account clinical expertise, judgment, critical thinking, analysis,
problem solving, decision-making, leadership.
Quality assurance and improvement: Scopes of practice should reflect measures that have
been implemented for the protection of the population served.
Risk assessment: Take into consideration risk to patients.
Evidence-based practices: Degree to which practices are based on valid scientific evidence.
Setting and culture: To be sensitive to place, context, and culture in which the practice occurs.
Legal liability and insurance: Should reflect case law and the legal liability assumed by the
healthcare provider, including mutual professional malpractice protection or liability insurance
coverage.
Regulation: Should reflect the legislative and regulatory authority, where applicable, of the
healthcare provider.
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
11
Individual Scope of Practice
While the scope of practice of the nursing profession defines the boundaries of the discipline of nursing,
the scope of practice of an individual registered nurse may be constrained by education, experience, and
the authority given to that registered nurse to perform all of the functions outlined within the definition
of the practice of nursing. Scope of practice does not define a level of practice but instead identifies the
range or extent of practice within specified limits, encompassing a nurse’s competency as well as
personal philosophies of care (Schuiling, Slager, 2000). Scope of practice does not specify for whom a
registered nurse may provide care but assists in identifying how that care may be provided in a particular
setting (Ibid, 2000).
Schuiling and Slager further suggest that when determining an individual scope of practice, a registered
nurse should consider factors that include education and experience, as well as:
 public need (needs of the client population and complexity of care)
 agreement of stakeholders (characteristics of the healthcare providers)
 support within the practice setting (organizational resources and the context of the
practice situation, such as scope of employment)
 philosophy of a professional organization (e.g., Canadian Association of Critical Care
Nurses)
 mandate of the regulatory body, including legislation, regulations, standards for practice,
core competencies, and available resources
 collaborative relationships
 individual practice experience
 individual philosophy of care.
These factors provide both inflexible boundaries, outside of which one is not practising nursing, and
flexible boundaries, such as clinical parameters, that vary according to the experience of the practitioner,
practice environment, patient population, and practice guidelines. Even though complex, a clear
determination of the scope of nursing practice enables registered nurses to practise safely and effectively
to the full extent of their capabilities so that consumers of nursing services are protected (Canadian
Nurses Association, 1993).
Registered nurses should keep in mind that the utilization of an extensive knowledge base of nursing is
the basis for professional judgment and that skill as decision-makers and problem solvers forms a
significant part of nursing practice; thereby, necessitating moving beyond the physical tasks of caring
that at times are interpreted by the population served and other healthcare providers as the practice of
nursing (Canadian Nurses Association, 1993).
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
12
Full Scope of Practice
Every registered nurse has the capacity to work to a full scope of practice within the profession. In
relation to advanced nursing practice, the Canadian Nurses Association (2002) states that it:
“occurs within the full scope of nursing practice, a scope of practice that is dynamic and has
flexible boundaries. It is the application of advanced nursing knowledge that determines whether
nursing practice is advanced, not the addition of functions from other professions.”
Assuming that all registered nurses can work towards a full scope of practice, there may not be a need to
include a separate category in “scope of practice” for advanced nursing practice. All registered nurses
must take the opportunity to be involved in creating new roles and expanding current roles, thereby,
moving along a continuum of education and experience by acquiring competencies that are incorporated
into their individual practice.
Full scope of practice encompasses much more than interventions and it is clear that registered nurses
share aspects of numerous interventions and competencies with other healthcare providers. Before
determining individual scope of nursing practice, it is useful for nurses to think in terms of competencies
rather than skills or tasks. Competency, by definition, refers to an individual’s ongoing ability to
demonstrate a simultaneous integration of knowledge, skills, and attitudes required for performance in a
designated role and setting in the workplace (Registered Nurses Regulations, 2009; Alspach, 1995).
Working to a full scope of practice supports the notion that all healthcare providers can be utilized to the
full range of their role, responsibilities, and functions for which they are educated, competent, and
authorized to perform (Health Authorities Health Professions Act Regulations Review Committee,
2002). Within the scope of practice legislated by law, all registered nurses can practise to the full extent
of their individual level of competency based on their education and experience (Canadian Nurses
Association [background paper], 2003).
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
13
Components of Scope of Practice for Registered Nurses
This section highlights the major components that comprise the scope of practice of registered nurses, as
described in the nursing literature and validated by registered nurses in Nova Scotia. Examples of
nursing scope of practice have been extracted from the current nursing literature and, where possible,
supported by the views of registered nurses working in Nova Scotia (noted in italics). Registered nurses
representing diverse nursing backgrounds articulated these views while attending focus groups
conducted by the College in 2004.
The Canadian Nurses Association (2002) identifies the domains of nursing practice for registered nurses
as clinical practice (direct care), education, research, and administration. These domains are well
represented in current nursing literature, as are four themes typically associated with the scope of
practice of registered nurses: nursing process, professional nursing relationships, leadership, and
teaching and learning.
Nursing Process
The scope of practice of registered nurses is based on substantial specialized knowledge of nursing
theory and is applicable in all four domains of nursing practice. The application of nursing
knowledge/theory is the basis for the scope of practice of registered nurses, with different nursing
theories being applicable in different settings, different situations, and in meeting the varied healthcare
needs of individuals, groups and communities.
Examining the scope of practice of registered nurses begins with a review of critical thinking. There are
three types of critical thinking competencies that registered nurses employ when making decisions and
judgments about clients: 1) general critical thinking that utilizes the processes of the scientific method,
problem solving and decision-making; 2) specific critical thinking in clinical situations that utilizes
diagnostic reasoning, clinical inferences and clinical decision-making, and 3) specific critical thinking in
nursing that utilizes the nursing process (Kataoka-Yahiro and Saylor, 1994).
Within the model for critical thinking in nursing judgment described by Kataoka-Yahiro and Saylor the
outcome is “nursing judgment that is relevant to nursing problems in a variety of settings”. This model
begins with five components of critical thinking: specific knowledge base, experience, competencies (as
stated above), attitudes, and standards. Registered nurses utilize all these components when thinking
critically about nursing problems, with the nursing process being the traditional critical thinking
competency that enables them to make clinical judgments and take actions based on reason. When
caring for clients, registered nurses simultaneously synthesize the critical thinking components while
engaging in the nursing process (Potter & Perry, 2001).
Registered nurses in Nova Scotia describe their knowledge base as extensive and broad-based. By
utilizing nursing knowledge and theory in the role of a registered nurse they interpret their work as
intellectual. They recognize themselves as problem solvers and decision makers.
Decision-making is an end point in critical thinking, leading to problem resolution. If a registered nurse
thinks critically, the client becomes an active participant and the ultimate outcome is a comprehensive,
individualized approach to care (Potter & Perry, 2001).
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
14
Potter & Perry (2001) describe the nursing process framework as dynamic and continuous, not a linear
process with a clear progression from one phase to another. Nurses individualize care in order to
respond to client needs in a timely manner, so that a level of health improves or is maintained. Use of
the nursing process differentiates the registered nurse’s practice from the practice of other health
professionals because of its broad focus on understanding and managing a person’s health. In clinical
practice registered nurses have two focuses — as a primary provider of nursing care and as a
collaborator with other disciplines.
Assessment
In our current healthcare system registered nurses must solve problems accurately, thoroughly and
quickly. They must be able to review information from a variety of sources and make critical judgments.
Data is systematically collected from a primary source (i.e., the individual) and also secondary sources
such as the family or other health providers, then verified and analyzed (Potter & Perry, 2001).
Assessment contributes to maintaining individual patient safety as the highest priority (Cowman,
Farrelly, and Gilheany, 2001).
This is one reason why RNs complete an assessment that is broader than other disciplines —
encompassing all responses, including those of the family, and any complications so that we have the
whole picture. One RN described a situation where a mother was waiting for the RN to arrive because
she felt her son, who had a Stage IV neuroblastoma, should have a CT scan — even though the decision
was made that nothing more could be done. The RN recognized this mother’s need and arranged for the
test to occur, resulting in the mother taking her son home with the information she needed in order to
cope.
The purpose of an assessment is to establish a database about a client’s perceived needs, health
problems, responses to these problems, related experiences, health practices, goals, values, lifestyle and
expectations from the healthcare system (Potter & Perry, 2001). The continuous nature of nursing care
and consistent presence of registered nurses in a care setting contributes to a holistic assessment process
that considers the patient’s strengths and needs, and provides a basis for maximizing the client’s
personal resources in the process of care (Cowman, Farrelly, and Gilheany, 2001).
In my role as an RN I was able to help a patient who wanted to go home to die by arranging for that to
happen. The family was very thankful afterward and stated that the way this request was handled was
very helpful to them.
Assessment is a key component of the nursing process and includes strong, theoretical and clinical
assessment skills as an essential component of nursing work. Those skills include observation,
questioning, vigilance, monitoring, anticipation of events, preventing problems, watching over people
and circumstances, knowing the person, knowing the networks, knowing the contexts and pulling it all
together (Jones and Cheek, 2003). Jeanne Besner (2004) comments that a large part of the role of
nursing role is found in assessment. She notes that tasks are the same but the management of care is very
different for each client, and that accurate assessment takes time and can become complex, especially
considering that 30 percent of our population has a Grade Six education or less. Based on this idea of
assessment, nursing intervention changes from doing just anything to doing something based on all the
information.
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
15
One participant shared an experience concerning an elderly lady who was suffering from mental illness
and was being cared for in an acute care setting. In transitioning from acute care to outreach, she was
placed in an LTC facility. She was very unhappy and wanted to go home with her husband. She relied on
her husband, never let him out of her sight and he did everything for her. When seen by the community
mental health nurse she again stated how unhappy she was and her husband also voiced his
unhappiness — he wanted his wife home. Recognizing that the lady had never been seen at baseline for
her mental illness, the RN put things in place so that she could go home with certain conditions. After
six months the lady’s cognitive functioning had improved and she was thriving.
Registered nurses frequently assess patients and attend to cues that lead to the recognition of
complications by monitoring often and thoroughly and by digesting recorded information. This is called
surveillance. Often registered nurses are the first to detect early signs of possible complications and their
vigilance makes timely rescue responses more likely. Nurses recognize and then manage complications
before potential catastrophic events (Clarke and Aiken, 2003).
One RN described a child who was sick with asthma and seen in the emergency department. The
physician ordered aerosols and said to send the child home. With decreasing SATs and a chest
assessment that indicated respiratory distress, the RN assessed the child as being too sick to go home.
The physician still stated the child was to go home. The RN called the Regional Health Centre and
arranged for the child to be seen there. On arrival, the child was accepted and spent six days in the
hospital.
Another aspect of surveillance is the availability of experienced registered nurses for consultation and
observation of clients of novice nurses, for early signs of distress (Clarke and Aiken, 2003).
One RN reported that student nurses in their third year “co-op” experience describe how invaluable it
is to have the experience of nurses nearby and how overwhelming it is when they (students) actually
have to apply what they have learned. The whole experience really helps them see what nursing is all
about and they value the mentoring they receive from more experienced RNs.
Registered nurses have high levels of information about individual patients and their health status and
contribute significantly to interdisciplinary discussions and decisions (Schim, Thornburg and
Kravutske, 2001).
When one registered nurse recognized that specific needs of a family were not being met she acted as a
change agent in challenging other RNs to think differently about the care they were providing and under
her guidance they worked through some concepts with which they were previously unfamiliar. The result
was the arrangement of a family conference, which proved very successful in meeting the needs of the
family. Registered nurses collaborate with all other disciplines. As RNs we make sure the client reaches
the right outcome. This requires excellent communication skills, including the use of documentation.
All registered nurses must function at a level of autonomy where ongoing assessment and evaluation of
a client’s condition is performed, possibly including the display of high-level technical troubleshooting
skills, immediate problem solving skills for highly complex equipment, and the notification of a
resource person according to established criteria (Christiansen, 2000).
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
16
After completing a nursing assessment, registered nurses can then form appropriate nursing diagnoses
— clinical judgments about a client’s responses to actual or potential health problems or life processes.
The assessment is the basis for planning individualized nursing care, and registered nurses evaluate and
refine this care as required while caring for a client (Potter & Perry, 2001).
Planning
During the planning phase of the nursing process, client-centered goals and expected outcomes are
established, priorities are set in order of importance, and nursing interventions are selected. Establishing
priorities assists registered nurses in anticipating and sequencing nursing interactions when a client has
multiple problems or alternatives (Potter & Perry, 2001).
A registered nurse working in long-term care was providing care for a resident who had very complex
healthcare needs. The resident’s daughter was very nervous about the whole situation. The RN took the
time to prepare and then discuss a plan with the family, which with their input turned out to meet the
resident’s needs very well.
For registered nurses, planning care can be independent or interdependent with other health providers
and includes sharing of information and discussing care options in relation to family situations, patient
care activities and patient discharge. As part of the planning process, registered nurses consult on rounds
with the care team, and develop a plan to meet a client’s discharge needs, including anticipation of
potential high-risk situations for both the patient and staff (Cowman, Farrelly, and Gilheany, 2001).
One RN recounted how she spent four hours on the phone during a busy shift trying to find a bed in the
province for the specific needs of a patient with mental illness. She was successful but was well aware
that her activity could have been interpreted by others and the public as “being on the phone all day”.
When patients participate in the planning process, they are developing partnerships with registered
nurses. Registered nurses meet patients where they are and for what they need (Cowman, Farrelly and
Gilheany, 2001).
A client receiving care following surgery remarked on not having contact with a registered nurse until it
was time to go home. At that point the client was included in the planning and they discussed whether
she had met her health outcome, and then arranged for the follow-up care.
Registered nurses recognize that every patient is unique and that patients want a partnership with the
care provider. Even when some patients may not have the literacy skills needed in order to understand
their health needs, registered nurses must meet the patient’s needs, whatever the circumstance. As RNs,
we are not into activities but into outcomes.
Using their breadth and depth of knowledge, registered nurses contribute to team decisions regarding
therapeutic interventions, which is a key factor in the interdisciplinary process and central to key
decisions about patient care issues (Cowman, Farrelly and Gilheany, 2001).
Often, as registered nurses, we bring other disciplines in and work as part of a multidisciplinary team.
We are the planners. We intervene and assess responses, including the family’s, to ensure that discharge
planning is in place. Generally, RNs coordinate care and are the hub, ensuring that all pieces are in
place, so that each discipline does their piece and RNs pull it all together.
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
17
Implementation
Implementation may begin directly after assessment, but most often follows the planning stage. Highlevel critical thinking is expected during the implementation stage of the nursing process.
Registered nurses see beyond what is in front of the client and determine how to make it better for
tomorrow. They have a voice and can bring about change. They look at systems now to see how things
fit and function and work more effectively.
One RN described a situation where a loved one was dying and it was very important for the family to
know that their family member was comfortable and not in pain. The RN described how powerful it was
to be able to influence care decisions as well as bringing into consideration the ethics involved. She
described being instrumental in helping the physician move from a comfort level with healing to
understanding the process of caring for the dying. Often RNs can influence decisions regarding pain
management, especially in LTC, and find that care team members, including physicians, listen more and
work with more of a team spirit.
The actions of implementation include evaluating the complexity and predictability of a client’s care
needs; managing negative outcomes and exhibiting a high level of clinical decision-making; recognizing
subtle signs and symptoms; anticipating unique interventions, and communicating, coordinating, and
priorizing (Christiansen, 2000).
One RN described how a patient was dying of CHF and was struggling to breathe. This patient was
under the care of a GP, with input from the specialist who recommended that the only thing to do was to
give Morphine aerosols. The RN knew of other treatments for-end-stage CHF such as the initiation of
Dobutrex and suggested that while in discussion with the GP. The GP called the specialist who
responded negatively and did not order any different medication. The patient died suffering. When asked
how the RN moved on from this experience she said that she developed more assertiveness in handling
patient advocacy so that it wouldn’t happen again.
Registered nurses select and initiate interventions that are most likely to support or improve a client’s
health status. Nursing intervention includes performing, assisting, or directing the performance of
activities of daily living, counseling and teaching clients. As well as providing direct care, registered
nurses supervise, delegate, and evaluate the work of other staff members, and record and exchange
information relevant to a client’s continued health care. Implementation is a continuous part of the
nursing process and activities are adjusted as a client’s condition changes (Potter & Perry, 2001).
A registered nurse described the experience of working with one particular patient who was very
challenging and exhibited difficult behaviours such as self-abuse. The RN always wondered if she had
made a difference in this girl’s life as it was so challenging to work with her. Ten years later the RN and
this young woman now work together with members of a self-help group and she is involved with a lot of
public speaking about the issue of self-abuse. This woman told the RN what a difference she and other
members of the health team had made when she had been so ill. She verbalized her appreciation to the
RN.
In a crisis registered nurses quickly institute appropriate measures by initiating first-line emergency
measures, activating a team response by alerting appropriate team members, conveying the urgency
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
18
needed at the bedside, and clearly communicating with other personnel while exerting control over the
situation to ensure appropriate actions are taken. (Clarke and Aiken, 2003)
It is frustrating when someone is going ‘bad’ and non-nursing [administration] is not listening to you …
when it is evident you have the knowledge and experience. There is only co-dependency with physicians
when implementing some interventions.
Interventions can be nurse-initiated, physician-initiated, or collaborative. Registered nurses anticipate
possible complications and assemble necessary supplies and equipment at the bedside before and during
a crisis, and administer lifesaving treatment while assessing patients and gathering information (Clarke
and Aiken, 2003).
RNs are often involved in end-of-life issues. An RN described how a 40-year-old mentally-challenged
woman was admitted to ICU and intubated. However, her disease process progressed and treatment was
going to be withdrawn. Her sisters came in to visit her and told stories about their sister, helping the
RNs get to know the patient as a person. The RN felt she made the end-of-life journey easier for the
family and when asked how she stated by listening, caring and crying with the family.
Evaluation
The evaluation step of the nursing process measures a client’s response to nursing actions and the
progress made towards achieving health goals. Managing client follow-up and maintaining continuity of
care and health promotion/disease prevention activities can all be considered part of the evaluation
process (O’Connor, 1999).
Registered nurses commented on several different nursing actions that helped measure clients’
responses to nursing actions. For example, expectant mothers now have increased prenatal preparation
because the post-natal stay in hospital is so short. RNs see their role as making a difference in terms of
health outcomes, especially when they see clients in good health after having been in ICU in poor
health. Registered nurses feel proud when they see other RNs promote a cause and make a positive
impact regarding the use of seatbelts and helmets.
Evaluation is considered one of the most critical phases of the nursing process because the basis for
evaluation supports whether client-driven and client-centred nursing practice is effective. As part of the
evaluation process, registered nurses measure the quality of nursing care provided in a healthcare
setting. Client care is complex and registered nurses are key in helping organizations find ways to
improve the quality of care (Potter & Perry, 2001).
There is more technology, it is more specialized, less task oriented. There is opportunity and diversity —
many models of care (e.g., in mental health, we are moving away from the medical model and utilizing
nursing models. Administrative structure has moved from authoritative to governance — RNs are now
involved in decision-making. There is more evidence-based practice. Registered nurses either spearhead
or work closely with Quality Assurance Programs in implementing and measuring quality of care
initiatives.
As a public health nurse, I was working with a single mother who had very little family support and was
living on her own and going to school. I provided support and encouragement, especially when exams
were approaching. When she got her marks she shared them with me and excitably described her plan
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
19
for the future, which included going to technical college. Because of the support I provided in my role as
a registered nurse this mother was comfortable sharing her plan to change her life.
Professional Nursing Relationships
Success in establishing professional relationships is more likely to occur when registered nurses follow a
philosophy based on caring and respect for others. To create professional relationships, registered nurses
must apply knowledge, display an understanding of human behaviour and communication, and be
committed to (engage in) ethical behaviour (Potter & Perry, 2001). The caring interaction between a
registered nurse and a client includes a physical, safety, and social dimension; the provision of
information, including spiritual information; the provision of a range of treatment modalities, including
pharmaceutical interventions; and encouraging self-determination (Cowman, Farrelly and Gilheany,
2001).
One RN described a situation in which a couple that had previously experienced the delivery of a very
pre-term baby that was not viable was unfortunately facing the same situation again. In order to cope,
they decided not to see the baby when it was born. This baby was born alive, though it would not
survive, and the RN wrapped the infant in warm blankets and held it in a quiet room with soothing music
for a few hours until the baby died. She tried to make this short life experience the best it could be. RNs
have moments that no one else has the opportunity to share.
Potter & Perry (2001) describe several types of professional nursing relationships: nurse-client, nursefamily, nurse-health team, and nurse-community. Depending on how an individual nurse defines
‘client’, the nurse-client relationship can be as specific as one individual requiring care or broad enough
to include a family or community. In any case, these relationships are the foundation of clinical nursing
practice and are viewed as the essential element of care with every client in every situation.
An emergency RN described how a young man with lots of potential and from a ‘good’ family was
diagnosed with schizophrenia and constantly appeared in emergency after overdosing. This young man
developed many problems, and it was extremely challenging to care for him and for his parents who
were trying to cope with his condition. In the past, these patients were not managed well and the only
medication that worked for him, to stop the noises in his head was Gravol. He was unpleasant to care
for and really wasn’t looking after himself. He was a challenge to the whole emergency team. This went
on for many years and the staff continued to look after him until, finally, a medication was developed
that could work for him. He now looks wonderful, has a job, and hasn’t been seen in the emergency
department for five years He survived with help from the emergency staff and his supportive family —
nobody gave up on him.
Another RN described an experience where a patient was dying and the family members, who had
remained in the room for lengthy periods of time ,were exhausted. Since it was unclear when the patient
would die, the RN suggested that the family go home and she would call them if there were any
significant changes in the patient’s condition. About an hour later there was a significant change and
the RN called the family. They got all the relatives together and everyone was present when the
individual passed away. They were all very thankful to be there as they were unable to be present when
their mother passed away. It made a difference to have all the relatives there.
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
20
One RN described a situation where a physician and an RN in a palliative care setting had reached an
impasse. Both were in defensive stances and there was a moment of silence. At this point the RN became
visibly non-threatening and said to the physician, “Help me understand your rationale for this decision,
I need to know what you are thinking.” This statement made a huge difference and they were able to
move forward with further decision-making.
Within the registered nurse’s role, and based on the premise that every client is unique, the therapeutic
relationship occurs within a specific timeframe and is goal-directed, with a high expectation of
confidentiality. The helping or therapeutic relationship is created with care and skill and built on a
client’s trust in a nurse (Potter & Perry, 2001). Registered nurses describe “doing with” as supporting,
supervising, and working alongside patients, while “being with” means providing a presence where
other active interventions are not possible (Cowman, Farrelly and Gilheany, 2001).
Several RNs in an emergency department demonstrated confidence and compassion by “being with” a
family during a catastrophic event. It was following a car accident where one child died, another was
airlifted to hospital, the mother was badly injured and the husband was at home. He was called to the
hospital and it was there that he was informed of the enormity of the situation. The crisis worker
described how amazing it was that even though he had to be there, several RNs came and stayed with
the family and provided support as they waited at the hospital. Several nurses who need not have been
there came anyway to be quietly present, touching, and providing a private environment.
Relationship activities reflect how nurses are “with” patients more than what they “do to” patients.
Aspects of these activities include caring, personalizing care, being customer-centred, and being ethical
and respectful. In a study conducted by Schim, Thornburg and Kravutske (2001), ambulatory nurses
gave the most value to independent functions such as client teaching, coordinating, and relationship
building with clients and colleagues.
One RN described how her mother-in-law was diagnosed with cancer on a Monday and died one week
later. Since she wanted to be cared for at home by particular family members, the RNs adopted the
shared-care model and taught the family to care for her at home. This request is happening more and
more as many family members receive care from family caregivers in their homes. The role of the RN is
to teach these caregivers everything they need to know to provide that care.
In the current healthcare climate, a growing emphasis is being placed on nurse-health team relationships.
These collegial relationships focus on accomplishing the work and goals in clinical settings.
Communication is crucial in these relationships and includes team building, facilitating group process,
collaboration, consultation, delegation, supervision, and leadership. Many registered nurses assume
these aspects of collegial relationships. Communication is key to the success of the healthcare team and
all team members need to be able to communicate with and support staff members who are experiencing
difficulty (Schim, Thornburg and Kravutske, 2001).
We need to be better in making the team aware of what we need to know. Sometimes we don’t get the
proper information because other team members aren’t aware. Often our work is invisible and we need
to define or explain it better to healthcare team members and the public.
RNs are good in administration – they are excellent communicators and are often communicating on the
spot and in a hurry, while at the same time negotiating the next step. RNs are flexible and this is seen
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
21
when they do or don’t make a connection with a patient or family. Patients have the right to choose who
cares for them and we have to be ready to send in someone else who can make a better connection. RNs
wear many hats.
That being said, registered nurses can feel marginalized when organizations move forward with major
change without asking for or in some cases discounting their opinions. Communication is the core of
nursing practice and Jones and Cheek (2003) describe it as having a passion for people that leads to
effectively working alongside people, networking, and at the same time working in an interdisciplinary
manner.
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
22
Leadership
The modern leader is seen as a coordinator of a complex system. And in today’s complex healthcare
environment registered nurses, at all levels, are leaders. For example, individually registered nurses
mentor and motivate, within groups they build teams and resolve conflicts, and organizationally they
build culture (Potter & Perry, 2001).
Registered nurses not only set the direction, but also assist in problem solving and overseeing outcomes
as demonstrated by their use of critical thinking, clinical leadership, case coordination, resource
management and utilization (Health Authorities Health Professions Act Regulations Review Committee,
2002). In fact, as leaders, registered nurses report that the following themes are part of their scope of
practice: flexibility, adaptability, expecting the unexpected and dealing with an ever-changing
environment, people and politics, management and leadership, and dealing with conflict (Jones and
Cheek, 2003).
We are around 24 hours a day, 7 days a week, 365 days a year. We provide continuity – we pull
everything together. As registered nurses we focus on looking at the ‘person’ and whether they are
involved. We look to the overall outcome and what everyone contributes. We see the broader picture.
We use a holistic approach. We communicate and coordinate a lot of the implementation based on the
suggestions of other disciplines.
An elderly patient with no family was dying and requested to see his dog before he died. The hospital
had a policy that no animals were allowed in the building. The nurse worked on changing the rules and
the dog was allowed to visit with the patient. After the man died, the nurse continued to move forward
and the hospital changed its policy to be more patient-centered.
Registered nurses demonstrate leadership by performing a central coordinating role, including
coordinating the services of nurses and other professionals for the patient and matching patient needs
with available services (Cowman, Farrelly and Gilheany, 2001). Other examples of coordination include
delegation, supervision of unregulated care providers, patient advocacy, working with other disciplines,
resource identification, and the referral of tasks (Schim, Thornburg and Kravutske, 2001).
Other roles of registered nurses, including that of nurse/patient advocate and mediator (between the
patient and other professionals) rely on the capacity of registered nurses as leaders in navigating the
patient through the healthcare system (Cowman, Farrelly and Gilheany, 2001).
As health professionals we are all patient advocates. We share in patient care, assessment, interventions
and counseling … and we all strive to provide quality patient care. As registered nurses we look at the
whole system and assess the physical, the emotional, and the family. Not only clients but also other
disciplines bring their issues to registered nurses, and the RN coordinates the care. Registered nurses
coordinate care, along the whole continuum, and act as the maze navigators … ensuring care happens
… and doing so in as timely a fashion as possible.
RNs must be leaders of the team to ensure that care is adequately provided, particularly in situations
where there is increased intensity, unpredictable changes in clients and/or unstable patients. The
provision of appropriate and safe nursing care relies on the competency of RNs. The clinical judgment
of registered nurses is based on knowledge and appropriate competencies, and when combined with
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
23
problem solving results in decision-making (Nurses Association of New Brunswick and the Association
of New Brunswick Licensed Practical Nurses, 2003).
As members of a profession, registered nurses have autonomy in decision-making and practice — that is
the ability to be self-directive in accomplishing goals and advocating for others. Nursing interventions
are independent responses to a client’s health care needs. These autonomous actions are based on
scientific rationale and require no supervision or direction from others. Also, registered nurses must
support the autonomy of client by respecting and upholding their rights to their own values and
decisions (Potter & Perry, 2001).
RNs take accountability for the overall journey of the patient when sometimes it is difficult to see that
overall picture or outcome. We must bear in mind that patients have rights and must take accountability
for their choices too – we don’t own their choices. Generally, many patients self-administer their own
meds yet that activity is taken away while they are in hospital. We need to consider a self-care model. If
a patient is discharged but must wait an hour for a ride, it is their responsibility to take their medication
not the RNs as they have been discharged – yet we worry about this.
In the current healthcare climate it is important for registered nurses to focus on competencies; the
ability to lead and/or participate in interdisciplinary healthcare teams; experience and expertise; and
independent judgment and clinical decision-making, rather than on being pre-occupied with tasks
(Health Authorities Health Professions Act Regulations Review Committee, 2002).
Teaching and Learning
Teaching is an interactive process that promotes learning. It is a conscious, deliberate set of actions that
assists an individual in gaining new knowledge, changing attitudes, adopting new behaviours, or
performing new skills. Readiness to learn occurs when an individual identifies a need, and teaching is
most effective when it responds to an individual’s learning needs (Potter & Perry, 2001).
A registered nurse working in the emergency department of a regional facility describes an experience
where an individual came to the Emergency Department after having a heart attack the day before.
Everything was new and cardiac teaching was required. Fortunately on this day there was time to spend
on teaching that was then reiterated by the physician with the patient. It was clear that all the
information was consistent between the health care providers and the RN was proud of that. In this case
it helped to know the patient personally so that the teaching better met his learning needs. Emergency
was described as the entry point and exit point for lots of people and it is a time where it is really
important to do that teaching at that time of contact. Often teaching gets done but you have to squeeze it
in as best you can. The patient also offered good feedback about the experience.
Regrettably, in health care, it has often been difficult to meet the individual learning needs of the client
and thus teaching occurs at the convenience of the health care system. This convenience for the system
causes clients from diverse backgrounds who utilize a variety of coping skills, to experience
unnecessary stress and haphazard learning that results in wasted time and a strain on resources as they
must move slowly through the health care system.
Often patient teaching is cut short and is not as good as it could be. For example a man with a Port-aCath was discharged home and had no idea about the care that was required and had not received any
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
24
teaching. He had just been sent home. On arrival at the clinic the RN seeing him had to re-initiate all
the teaching.
RNs meet patients where they are and for what they need – sit down, teach and explain
Patients want a partnership with care providers so there are lots of opportunities for teaching.
It is frustrating when there is a lack of resources to back up education and training for all staff.
Teaching the patient is part of the RN’s role. RNs must be encouraged and also supported to teach and
this starts with the managers. In some settings, we don’t have the support/structure anymore to facilitate
teaching.
In the current health care climate, there is movement towards increasing the focus on health education
and health promotion, requiring RNs to retain a pivotal role in educating themselves, students, other
RNs, staff, patients and the public (Cowman, Farrelly, Gilheany, 2001).
In working with Dalhousie students, one RN shared how the students helped in the development of a
project to assist patients diagnosed with diabetes to learn more about the disease. The students had to
learn what they were to teach and then teach the families information and skills to manage their disease.
With the preceptor’s guidance the students did very well and the families had a very positive experience,
the students also said they felt more confident in delivering the care required for families dealing with
diabetes. For them it was putting the whole picture together in the clinical setting.
Since registered nurses have an ethical responsibility to teach their clients they must adopt a philosophy
of lifelong learning (Potter & Perry, 2001, Jones and Cheek, 2003). The role of the RN is to anticipate
the client’s needs for information and then be responsible for teaching that information. In other words,
to be effective as an educator, registered nurses must determine what clients need to know, create a
learning environment and then evaluate the outcomes after learning has occurred (Potter & Perry, 2001).
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
25
Summary
As health human resource planning evolves in Nova Scotia, registered nurses are in a key position to
effectively contribute to the decision-making that determines the skill mix required to meet the health
needs of the population they serve. Registered nurses in Nova Scotia must work individually and
collectively to their full scope of practice as the current health care environment is re-designed.
Determining what the full scope of practice is for an individual registered nurse is a necessary first step
and begins with a review of the broad definition of nursing practice as described in legislation, a
reflection on the principles and criteria used by all health professionals and finally an examination of the
factors that determine an individual nurse’s scope of practice, resulting in an accurate interpretation of
what full scope of practice means for each individual registered nurse.
It is clear from the nursing literature and from examples provided by registered nurses in Nova Scotia
that the scope of practice of the registered nurse is key in the delivery of health care and that this
knowledge is useful as registered nurses examine their individual’s and profession’s scope of practice in
inter-disciplinary health care settings. A clear articulation of full scope of practice enables registered
nurses and employers to make informed decisions related to the optimal staff mix in a particular health
care setting to better meet population health needs in Nova Scotia.
In 1993 the vision of the Canadian Nurses Association was that there will be significant opportunities
for nursing as the health care system continues to evolve. Changes in the structure of health care
delivery and the emergence of new technologies can’t help but expand opportunities for nursing. More
clearly defining the scope of nursing practice enables registered nurses to remain as a crucial part of a
health care system but with different nursing jobs. New nursing roles will evolve from the focus on
primary health care and health promotion in which nursing has historically had a strong presence and
therefore nurses can be well positioned to further expand practice in these areas (Canadian Nurses
Association, 1993).
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
26
Appendix
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
27
Full Scope of Practice of the Registered Nurse
The Profession’s Scope of Practice
Definition of the Practice of Nursing means the application of specialized and evidence based knowledge of nursing theory, health and human
sciences, inclusive of principles of primary health care, in the provision of professional services to a broad array of clients ranging from stable or
predictable to unstable or unpredictable, and includes
(i) assessing the client to establish their state of health and wellness;(ii) identifying the nursing diagnosis based on the client assessment and analysis
of all relevant data/information;(iii) developing and implementing the nursing component of the client’s plan of care;(iv) coordinating client care
in collaboration with other health care disciplines;(v) monitoring and adjusting the plan of care based on client responses;(iv) evaluating the
client’s outcomes; (vii) such other roles, functions and accountabilities within the scope of practice of the profession which support client safety
and quality care; in order to (A) promote, maintain or restore health; (B) prevent illness & disease; (C) manage acute illness; (D) manage chronic
disease; (E) provide palliative care; (F) provide rehabilitative care; (G) provide guidance and counseling; and (H) make referrals to other health
care providers and community resources; and also includes research, education, consultation, management, administration, regulation, policy or
system development relevant to the above
The Individual’s Scope of Practice
Principles and Criteria for Determining Scope of Practice
Criteria (*complete descriptions on back)
Principles (*complete descriptions on back)





Focus on the needs of the population served
Flexibility
Collaboration and cooperation
Coordination of individual patient care
Patient choice of health care provider





Accountability
Education
Competency and standards of practice
Quality assurance and improvement
Risk assessment
Evidence-based practices
Setting and culture
Legal liability & insurance
Regulation




Factors that Influence Scope of Practice
 the philosophy of a professional organization (e.g. Canadian Association of Critical
Care Nurses),

an individual philosophy of care
Nursing Theory: Self Care – Goal Attainment – Caring – System - Humanistic etc.
Critical Thinking - Competencies



General
Scientific Method
Problem solving
Decision making
+
Specific (Clinical)

Diagnostic reasoning

Clinical inferences

Clinical decision making
+

Specific (Nursing)
Nursing Process :Assessment,
Planning, Implementation,
Evaluation
Nursing Judgment
Nursing Process Framework**
 Assessment
 Planning
 Implementation
 Evaluation
Professional Nursing
Relationships**
Leadership**
** (complete descriptions on back)
Teaching and
Learning**
*Principles
Focus on the needs of the population served to promote safe, ethical, high quality care that is timely, affordable, and provided by competent health care providers.
Flexibility is an approach that is responsive to the needs of the population and enables providers to practise to the extent of their education, experience, and competency.
Collaboration and cooperation supports interdisciplinary approaches to health care and good health outcomes. An evidence-based approach and good communication are
essential.
Coordination of individual patient care is the role of a qualified health care provider and
Patient choice of health care provider should be taken into account
*Criteria
Accountability: The degree of, accountability, responsibility, and authority that the health care provider assumes for the outcome of their practice
Education: Consider the breadth, depth, and relevance of the health care provider’s education program taking into consideration provider certification and maintenance of
competency
Competency and standards of practice: Consider the degree of knowledge, values, attitudes and skills of the provider group. Take into account clinical expertise, judgment,
critical thinking, analysis, problem-solving, decision-making, leadership.
Quality assurance and improvement: Scopes of practice should reflect measures that have been implemented for the protection of the population served
Risk assessment: Includes taking into consideration risk to patients
Evidence-based practices: Degree to which practices are based on valid scientific evidence
Setting and culture: To be sensitive to place, context, and culture in which the practice occurs
Legal liability & insurance: Should reflect case law and the legal liability assumed by the health care provider including mutual professional malpractice protection or liability
insurance coverage
Regulation: Should reflect the legislative and regulatory authority where applicable, of the health care provider
Nursing Process Framework
Assessment
 gather client information
 critically examine and analyze data
 observation, vigilance, monitoring
 surveillance
 recognition of potential
 catastrophic events
 identify a client’s response to a health problem
Professional Nursing Relationships
 Nurse-client helping relationships
 Nurse-family relationships
 Nurse-health team relationships
 Nurse-community relationships
 Communication is key
Leadership
 Coordinator of a complex system
 Mentor & motivate
 Within groups build teams & resolve conflicts
 Organizationally build culture
Planning
 independent or interdependent
 information sharing
 discuss care options, consult on
 rounds
 develop a plan to meet client
 discharge needs
 anticipate potential high risk situations
 develop partnerships with clients
Implementation
 design expected outcomes
 evaluate complexity & predictability of care
needs
 managing negative outcomes
 exhibiting high level clinical decision-making
Evaluation
 evaluate whether the action is effective
Teaching and Learning
 pivotal role in educating themselves, students, other RNs, staff, patients and the public
 anticipate client needs for information,
 teach the information
 create a learning environment
 evaluate the outcomes
 Set the direction & oversee the outcomes
 Flexibility, adaptability, expecting the unexpected,
 Dealing with ever-changing environment, people & politics, management & leadership, dealing with
conflict
References
Alspach, J.G. (1995). The educational process in nursing staff development. St. Louis, MO: Mosby-Year Books.
Besner, J. (2004, November). Optimizing RN Scope of Practice Within a PHC Context: Linking Role
Accountabilities to Nursing Outcomes. Guest presentation to the staff of the College of Registered Nurses
of Nova Scotia, Halifax, NS.
Canadian Nurses Association. (1993). The scope of nursing practice: A review of issues and trends. Ottawa, ON:
Author.
Canadian Nurses Association. (2002). Position Statement: Advanced nursing practice. Ottawa, ON: Author.
Canadian Nurses Association. (2003a). Background paper: Patient safety – developing the right staff mix.
Ottawa, ON: Author.
Canadian Nurses Association. (2003). Joint Position Statement: Scopes of practice. Ottawa, ON: Author.
Canadian Nursing Advisory Committee. (2002). Our health, our future: Creating quality workplaces for
Canadian nurses. Ottawa, ON: Advisory Committee on Health Human Resources.
Christiansen, K. (2000). Is the role of circulating in an OR within the scope of practice for the RPN? Canadian
Operating Room Nursing Journal, 18 (1), 14-19.
Clarke, S.P., Aiken, L.H. (2003). Failure to rescue. American Journal of Nursing, 103 (1), 42-47.
College of Registered Nurses of Manitoba. (2002). Determining the scope of practice of an individual RN.
Winnipeg, MB: Author.
College of Registered Nurses of Nova Scotia. (2003). Delegation guidelines for registered nurses. Halifax, NS:
Author.
Cowman, S., Farrelly, M., Gilheany, P. (2001). An examination of the role and function of psychiatric nurses in
clinical practice in Ireland. Journal of Advanced Nursing, 34 (6), 745-753.
Davies, E., Fox-Young, S. (2000). Validating a scope of nursing practice decision-making framework.
International Journal of Nursing Studies, 39 (1), 85-93.
Government of Nova Scotia. (2006). Registered Nurses Act. Statutes of Nova Scotia, c.21, s.1.
Government of Nova Scotia. (2009). Registered Nurses Regulations, made under Section 8 of the Registered
Nurses Act, c. 21. Halifax, NS: Registry of Regulations.
Health Authorities Health Professions Act Regulations Review Committee. (2002). Toward increased integration
of LPNs into health authority employment settings. Calgary, AB: Author.
Health Care Human Resource Sector Council. (2003). A study of health human resources in Nova Scotia.
Halifax, NS: Author.
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
32
Jones, J. and Cheek, J. (2003). The scope of nursing in Australia: a snapshot of the challenges and skills needed.
Journal of Nursing Management, 11 (2), 121-129.
Kataoka-Yahiro, M., Saylor, C. (1994). A critical thinking model for nursing judgment. Journal of Nursing
Education, 33 (8), 351.
Kido, V.J. (2001). The UAP dilemma. Nursing Management, 32 (11), 27-29.
Lillibridge, J., Axford, R., Rowley, G. (2000). The contribution of nurses’ perceptions and actions in defining
scope and stabilizing professional boundaries of nursing practice. Collegian, 7 (4), 35-39.
Nurses Association of New Brunswick, and Association of New Brunswick Licensed Practical Nurses (2003).
Working together: A framework for the registered nurse and the licensed practical nurse.
Fredericton, NB: Authors.
O’Connor, T. (1999). When is nursing care not nursing care? Kai Tiake: Nursing New Zealand, 5 (4), 12-13.
Schim, S.M., Thornburg, P., Kravutske, M.E. (2001). Time, task, and talents in ambulatory care nursing. Journal
of Nursing Administration, 31 (6) 311-315.
Schuiling, K.D., Slager, J. (2000). Scope of practice: Freedom within limits. Journal of Midwifery and Women’s
Health, 45 (6), 465-471.
Tomblin Murphy, G., O’Brien-Pallas, L. (2002). Discussion Paper No. 30: How do health human resources
policies and practices inhibit change? A plan for the future. Ottawa, ON: Health Canada - Commission
on the Future of Health Care in Canada. Retrieved June 27, 2003, from
http://www.hc-sc.gc.ca/english/care/romanow/hcc0489.html
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
33
Bibliography
Anthony, M.K., Standing, T., Hertz, J.E. (2000). Factors influencing outcomes after delegation to unlicensed
assistive personnel. Journal of Nursing Administration, 30 (10), 474-481.
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. California, CA:
Addison-Wesley.
Bruser, S., Whittaker, S. (1998). Quality watch: diluting nurses’ scope of practice. American Journal of Nursing,
98 (10), 59-60.
Canadian Nurses Association. (2003). Backgrounder for dialogue: Scope of nursing practice and implications of
LPNs working to full scope of practice. Ottawa, ON: Author. (Includes CMA document Scopes of
Practice, 2002)
College of Registered Nurses of Manitoba. (1999). Decision-making: A framework for delegation. Winnipeg,
MB: Author.
Glazer, G. (2000). What makes something a nursing activity or task? Nursing World/Online Journal of Issues in
Nursing. Retrieved June 27, 2003, from http://www.nursingworld.org/ojin/tpclg/leg_9.htm
Glazer, G. (2002). Medication administration interventions that must be performed by a registered nurse. Nursing
World/Online Journal of Issues in Nursing. Retrieved June 27, 2003, from
http://www.nursingworld.org/ojin/tpclg/leg_12.htm
Kramer, M., Schmalenberg, C.E. (2003). Magnet hospital staff nurses describe clinical autonomy. Nursing
Outlook, 51 (1) 13-19.
Kummeth, P., de Ruiter H-P, Capelle, S. (2001). Developing a nursing assistant model: Having the right person
perform the right job. MedSurg Nursing, 10 (5), 255-263.
Potter, P.A., Perry, A.G. (2001). Canadian fundamentals of nursing, (2nd ed). New York: Mosby.
Registered Nurses Association of British Columbia. (2000). Delegating tasks to unregulated care providers.
Vancouver, BC: Author.
Registered Nurses Association of British Columbia. (2001). Regulating registered nurses in the public interest.
Vancouver, BC: Author.
Saskatchewan Registered Nurses Association. (2003). Model of clinical nursing practice: Staff mix guide.
Regina, SK: Author.
Saskatchewan Registered Nurses Association. (2003). RN (NP) and RN scope of practice. Regina, SK: Author.
Truglio-Londrigan, M., Macali, M.K., Bernstein, M., Kaider, G., Petersen, S., and Tumino, M.C. (2002). A plan
for the delegation of epinephrine administration in non-public schools to unlicensed assistive personnel.
Public Health Nursing, 19 (6), 412-422.
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
34
A Discussion Paper on the Scope of Nursing Practice for Registered Nurses in Nova Scotia
College of Registered Nurses of Nova Scotia
4005-7071 Bayers Rd, Halifax, NS B3L 2C2
Tel 491-9744 Toll-free (NS) 1-800-565-9744 Fax 491-9510
E-mail: info@crnns.ca Website: www.crnns.ca
Discussion Paper on the Scope of Practice of Registered Nurses in Nova Scotia
CRNNS
35