A post that is a little peripheral this week as it has more to do with the regulation of healthcare practice, but I must admit I am so frustrated with the anti-science agendas inherent in healthcare in BC I thought I would give vent to my thoughts here.
As a newcomer to Canada over 10 years ago, I must admit I have been somewhat perplexed by the rather laissez-faire regulation of healthcare in BC, and more worrying trend toward devaluing professional nursing practice. The regulation of healthcare in BC is a fascinating topic and not at all easy to follow because of the veritable jumble of regulators, and the complexity of providing the public safe access to the services they want. There are various levels of regulation. The highest level is the statutory regulation of healthcare practitioners under the BC Health Professions Act . This sets out the legal framework for professional regulatory bodies, to self-regulate their professions. Healthcare regulation is primarily designed to protect the public from unsafe practices and incompetent or unscrupulous practitioners. However, the regulation of professional health care practice in BC appears more a result of historical commercial and political influence rather than systematic rationale and well-conceived policy.
Firstly, unlike physicians, and many other health professions nursing is split between various regulators. RNs and NPs are regulated by the CRNBC, whilst RPNs are regulated by the CRPN and LPNs are regulated by the CLPNBC. This effectively breaks up the voice of nursing, and makes the qualifications and career pathways in nursing rather isolated, with very limited career-mobility between them. In April 2013 the CRNBC stated it was working with the BCNU and the ARNBC to review the regulation of nurses, so hopefully this has been recognized as an issue.
Secondly, the complaints and disciplinary structures in place for nurses in BC work very differently from other comparable countries. Only one person has been permanently removed from the CRNBC professional register in the last decade, and in the same decade only one disciplinary hearing was held; this despite the fact that there are 36,000 RNs on the register. The CRNBC prefers consensual resolution and suspension to removal (about 37 nurses a year are forcibly suspended), but that means they can regain their registration. The CRNBC states that “the majority of complaints are resolved through a consensual resolution process” which sounds fine, except that the suspensions include actions involving criminal and sexual offences, some of which would seem to warrant permanent removal from the register.
The CRNBC suggests its approach is more supportive than punitive, and that is to be applauded. Nevertheless, in California there are about nine times the number of RNs practicing than in BC, and there were 26 RNs licenses permanently revoked in June 2013. In equivalent numerical terms this would equate to us seeing around 30 nurses a year having their licenses permanently revoked here. Similar statistics to those in the USA are to be found with the NMC in the UK, and even in Ontario where there were 23 disciplinary case hearings in 2012 (out of about 60,000 RNs). I know these are not directly comparable, but even so something seems amiss. However, as the process is far from transparent (less details on disciplinary actions are available in Annual Reports now than 10 years ago) it is difficult to judge. Overall the system does seem to operate in more of a way that protects the professionals, rather than the public.
Thirdly, further regulatory concerns are raised by the increasing support for non-evidence-based practice (non-EBP) in BC, particularly with respect to complementary and alternative medicine (CAM). At this point I should acknowledge that there are many complementary health practices that are beneficial, and that can be shown to be empirically justified. Exercise based practices such as Yoga and Tai Chi have been shown to have good health benefits, and some good results have been achieved with clinical hypnotherapy and mindful-meditation in behaviour modification. Despite their theoretical basis being currently unsubstantiated in scientific terms, there is evidence of beneficial outcomes compared to placebo. Being open to alternative perspectives and possible beneficial interventions is in our interest as nurses, and we should always be prepared to consider new ideas.
We should also recognize that the Canadians love their CAM (over 50% of Canadian’s use some form of CAM) and so there is a significant public demand. I can certainly understand why the public want these services too. Modern technological medical healthcare is far from perfect. There are many things modern medicine cannot cure, and it is particularly ineffective at helping with many chronic conditions (such as acne, or tendonitis). It is also a victim of its own success. Most patients now receive very depersonalized care with rapid visits for screening, to see physicians or nurses, or for medical and surgical procedures. Also, modern medicine is usually very unpleasant, and as the predominant form of healthcare has rather a significant error rate. Procedures go wrong, people are frequently misdiagnosed, and sometimes people are injured or die as a result of medical practice.
As we have noted before, CAM practitioners operate primarily as primary providers, rarely deal with acute or emergency care, spend considerable time with patients and develop good working relationships with them over long-consultations. Their practices are generally quite non-invasive, often pleasant, and to paraphrase Douglas Adams “mostly harmless.” Contemporary postmodern nursing approaches taught in many Canadian universities are generally supportive of CAM practices. However, we should be clear, accepting a fashionable anti-science agenda and adopting constructivist philosophical arguments about the nature of evidence also has implications for our professional status.
A key example is that RNs in BC have now become regulated under one CAM profession that supports and practices mystical healthcare beliefs, advocates non-EBP (although claims to be evidence-based), has non-university and non-hospital based training (unlike physicians, physiotherapists, midwives and nurses who all have extensive clinical practicums in public hospitals and the community). If examine the CRNBC Scope of Practice, Section 7 (Restricted Activities that Require an Order) that health professionals authorized to give orders to registered nurses under the Regulation are dentists, midwives, naturopaths, nurse practitioners, physicians and podiatrists. Sadly, most of my graduate nursing students are unaware of the inclusion of naturopaths (since 2009) who are the only non-university and non-hospital trained profession on the list. This also seems completely as odds with the standard requiring nurses to use knowledge based practice (Standard 2), even thought the standard uses a very broad definition of evidence, it does appear to make some claim for nurses to use empirically supported practices.
No one seems too bothered it seems, but I for one, am not really comfortable being regulated to accept orders from practitioners that embrace what are essentially magical healthcare practices. I experienced this professional apathy first hand when I phoned the CRNBC to ask about the changes in regard to nursing orders in legislation from 2009. I was told by the CRNBC Practice Representative that “well there are different forms of evidence…” and anyway, not to worry as “naturopaths are university qualified doctors.” When I pointed out this was not the case and that naturopaths also have no university or hospital-based training, the CRNBC representative admitted they were unaware of this, but reassured me I shouldn’t worry as they were “regulated.” Interestingly, when I recently raised questions about the promotion of such therapies by nurses (such as in a letter to Canadian Nurse on the practice of Therapeutic Touch), I find I was labeled by nurses who wrote in as a narrow-minded positivist and similar. Sadly, this depicts a worrying lack of critical-thinking and worse a real misunderstanding of science and EBP in our profession.
Another point of interest here is the fact we are witnessing an increasing commercialization of healthcare in BC, and increasing support for recognition of private CAM practitioners in the system with practically no oversight. The whole CAM regulation enterprise is orientated towards the support of private practice. CAM practices may be mostly harmless, but some are decidedly not so (as in the case of Patricia Booth), and the preparation and regulation of these practitioners compared to the established science-based health professions of nursing and medicine is highly problematic.
With the case of naturopaths, they are fee-for-service practitioners that are qualified through two private colleges in Canada (one newly opened here in BC). They are identified as “doctors” on the basis of the length of their training, through self-identified awards from these private schools and accreditation from the US-based Council
on Naturopathic Medical Education that have now been recognized in the BC legislature. Nevertheless, no Canadian university recognizes a naturopathic doctorate as a doctoral level qualification. Their curriculum supports a peculiar mixture of science and magical beliefs, including naturalism, homeopathy, opposition to the germ theory of disease and vaccination. Both homeopathy and opposition to vaccination are in clear conflict with current EBP, and whilst homeopathy is pretty harmless, opposition to vaccination is certainly not.
Naturopaths are self- regulated through their own professional college (the College of Naturopathic Physicians of BC). However, unlike the CRNBC and the CPSBC who have a mandate to promote scientific EBP, the college appears to function by promoting their practices rather than by regulating theIr practitioners. The problem is if your professional regulatory body supports supernatural healthcare solutions, then they are unlikely to support complaints against practitioners who are providing them to patients. They may take action against practitioners who break the law, but what about practitioners who advocate and perform unsafe practices? For example, who do I complain to about naturopaths advocating homeopathic vaccines (that don’t work) to parents over established vaccines, the CNPBC? Likewise for chiropractors suggesting unscientifically supported practices such as chiropractic therapy for infants. As their own regulatory bodies actually support these practices there is effectively no oversight or public protection; pretty much anything goes: QED.
We should also be in no doubt CAM practices are not small homely operations, they represent a multi-million dollar industry (actually, a billion dollar trade, once you include the nutritional supplement industry; Offit, 2013). This fact may not have been lost on legislators in BC but has been picked up by some in the media, including being parodied on the Canadian Association of Witch Doctors website.
Overall, it would seem that Nurse Practitioners and Clinical Nurse Specialists are far-better experienced and more highly educationally prepared than CAM practitioners, and yet in BC they have now become significantly outnumbered by NDs, Chiropractors and other CAM professions. NPs are finding it difficult to find and take up positions reflect their skills in primary practice. The problem is that because of a lack of an effective nursing advocacy organization in BC this has come to pass without any significant opposition to what amounts to the devaluation of nursing practice.
Not only are the wheels coming off the regulatory bus, I think the bus is at risk of going over a cliff. Nurses have been struggling for the last century not to be perceived as medical hand-servants. If we don’t grasp these regulatory issues now then I fear nurses will become seen by the government as appropriate hand-servants for the latest CAM practitioners to gain legal recognition. I want to see professional NPs providing primary care in the community alongside other health-professionals, and better recognition of the role of advanced nursing practice by BC legislators.
So now we have a new professional organization (the ARNBC) I have hopes things will change positively for nurses. We need discussion on rationalizing the educational preparation, and regulation of all nurses across BC under a single regulatory body. Also it would seem timely for the CRNBC to review their complaints and disciplinary procedures. Lastly I suggest immediate action towards having the legislation adjusted to remove non-university prepared professionals from those able to give orders to nurses should be a priority. I fear the result of the current “dude, it’s all good” approach will not only be that the public is not effectively protected from harmful practitioners or practices, but also that nursing practice becomes increasingly devalued in the system. Let us not stand by and see that happen.
P.S. Please note all views expressed in this article are solely those of the author, and do not necessarily reflect the position of the UBC School of Nursing.
The BC Naturopathic Association: http://www.bcna.ca
The Health Professions Act: The College of Licensed Practical Nurses of BC: https://www.clpnbc.org
The College of Physicians and Surgeons of BC: https://www.cpsbc.ca
CRNBC Nursing Standards: https://www.crnbc.ca/Standards/Pages/Default.aspx
CRNBC Scope of Practice: https://www.crnbc.ca/archive/Documents/433ScopeforRegisteredNurses.pdf
CRNBC Annual Report Archives: https://www.crnbc.ca/crnbc/AnnualReports/Pages/Default.aspx
The College of Registered Psychiatric Nurses of BC: https://www.crpnbc.ca
Offit, P.A. (2013) Do you Believe in Magic: The Sense and Nonsense of Alternative Medicine. NY, Harper Collins
P.P.S. I offered this blogpost to the ARNBC blog, but they turned it down (so maybe things won’t be changing that much anytime soon)! 🙁