Canadian Nursing Association Resolution to Promote Science Based Nursing and Autonomy Fails

Hi all,

To publicize the fact that nurses are losing professional ground to magical healthcare practitioners here in BC, and that since 2009 nurses have been legally required to take orders from naturopaths, I submitted a resolution to the Canadian Nurses Association as an individual member to protect the autonomy of nursing in future.

I had previously raised this issue with the CRNBC and also with the ARNBC but neither were interested in pursuing it, (CRNBC is solely focused on regulation rather than looking out for the profession now) and it probably isn’t a key priority for ARNBC at the moment due to the ongoing legal battle with the BCNU.

The resolution simply suggested that the CNA advocate that registered nurses (RNs) in Canada not be subject to legislation that requires them to take direction/orders from other health care professions that do not have a superior level of both academic and clinical preparation (that must include Canadian publicly accredited university graduate level academic qualifications, and substantial hospital-based education and training in their field).The full resolution is available here.

This was considered at today’s annual meeting, and after a short debate (4 mins and 35 seconds) it was narrowly rejected by the members. I am not particularly surprised, but am rather saddened that the profession has not taken a simple action that would help strengthen the professional status of nursing in Canada, and protect nurses from further professional exploitation.

The arguments that went against it were mainly from BC (no surprise there) and were:

  1. It isn’t a problem as nurses can always refuse to act against orders given, and
  2. Strong language about using “Canadian” accredited qualifications and “superior levels of qualification” does not recognize the autonomy of other professions and international qualifications.

Vote

  • Yes: 77
  • No: 78
  • Abstain: 0

The point about international qualifications is reasonable. and could easily be included with an amendment such as “or equivalent” but the spirit of the resolution was clear enough, so a shame it didn’t pass with an amendment. Got support from the North West Territories though (yea, go NWT)!

Nurses continue to be at the mercy of political trends that leave new CAM practitioners who gain regulatory status the ability to identify themselves as better qualified than nurses though quackademic credentials. So, far from moving away from the role of “physicians handmaidens” and promoting advanced practice and professional autonomy nurses will continue to be seen as fair game in the Canadian healthcare system to become subservient to any complementary and alternative practitioners who care to call themselves “doctorally prepared” (through whatever means or credential).

So I guess I am to tell my students, you are “autonomous practitioners” in theory, but in the healthcare system at large you are recognized as subservient to anyone who holds a piece of paper that is recognized by the provincial government as some sort of health professional and wants to employ you. It is rather hard to promote a positive role for nursing when practitioners who actually practice magical healthcare and have US based quackademic qualifications are regulated above Canadian nurses. Maybe I’ll get ahead of the game and just set up a course in magical healthcare for nurses for our next undergraduate curriculum revision.

Sad times indeed, and I do wonder what the status of the RN will actually become over the next few years. Looks like reversion to a technical role in support of other health professionals is well on the cards, with the odd restricted role for specialist advanced practice (where the system is under-resourced). So, what happened to the CNAs stated aim to “strengthen nursing and the Canadian health system?”

Bernie

 

 

Are Nurses in British Columbia Licensed to Practice Magic?

Seasons greetings to all.

An Interesting Case

This year I decided to pursue a complaint against a practitioner with the College of Registered Nurses of British Columbia (CRNBC) for a nurse who was using their Registered Nurse (RN) title to market their own private Therapeutic Touch (TT) business. To those outside of the nursing profession this might seem a little confusing, but in other countries where I have worked as a nurse it is an established professional principle that you do not use your professional qualifications/status to promote your own for-profit activities outside of your role as an RN. The reasons for this would seem fairly self-evident. For example adding RN to your name gives you some professional credibility and it would be disingenuous to use it for personal gain, such as by selling something (be it real estate, car parts, vitamins or personal life-style counselling). The CRNBC has established standards governing use of title, and has even produced  guidance for practitioners with a case example to explain this. See: Can she Use her Title? where they note that having “RN” after your name may be seen as “…important in gaining the public trust and selling more product.”

Indeed, it was this very article that incited me to make the complaint as a test case, as I came across a TT practitioners website where the title of RN was explicitly used next to the practitioners name. I used the exact format and language in the guidance for the complaint and cited the relevant “Use of Professional Titles” standard and College Bylaws (sections 4 & 8)  in the complaint, and asked that the CRNBC to ask the practitioner not to use the RN title on their website. I had been in contact with this individual on other occasions and suggested that the use of RN was inappropriate to endorse this business activity. Unfortunately, I had a completely negative response, so a simple complaint to the CRNBC on appropriate use of title seemed an appropriate next step.

At this stage it is probably worth a quick recap on what the professional regulators function is. Basically, the regulation of nurses includes licensing, the creation of professional standards, enforcement of those standards, disciplinary measures and nursing education approval. Overall, the key principles that underpin the statutory professional regulation of nursing may be considered as:

(a) maintaining the safety and quality of the care that patients receive from health professionals;

(b) sustaining, improving and ensuring the professional standards of health professionals and identifying and addressing poor practice or bad behaviour;

(c) providing systems and legislation that sustain the confidence of both the public and the healthcare professions through demonstrable impartiality; and

(d) ensuring that the integrity of health professionals is sufficiently flexible to effectively meet the different health needs of the public and healthcare approaches can adapt to future changes and demands (Hewitt 2007; ICN 2014; Walsh 2012; WHO 2002).

To ensure that regulatory standards are effective, the regulatory process itself also needs to be seen as impartial and independent from the government, the professionals themselves, employers, educators and all the other interest groups involved in healthcare (Hewitt 2007). I.e. the CRNBC should represent the interests of the public at large rather than the profession or government (this is an important point, which we will come back to). So, one would think that in terms of public protection this complaint would represent a fairly straightforward case of inappropriate use of title to support a commercial enterprise.

Another consideration here is that in this case the title was being used to help market a completely unscientific, non-evidence based and “unverifiable” practice (as indicated by the CRNBC’s own Bylaws, 2012; Section 8.04). We have discussed the merits of TT on this blog before, and it is of course, pure magic in the terms it is portrayed (remote healing using undetectable energies) with no-scientific evidence to support efficacy. A 1999 review of the physics of complementary therapies states that the existence of a “bio-field” or “bio-energetic field” directly contradicts principles of physics, chemistry, and biology (Stenger, 1999). A recent Cochrane systematic review found “no robust evidence that TT promotes healing of acute wounds (O’Mathúna et al, 2012). The American Cancer Society stated in 1999, “Available scientific evidence does not support any claims that TT can cure cancer or other diseases” (AMA, 2012).  Lastly we have the youngest person ever to get a paper published in the Journal of the American Medical Association ( the nine year old Emily Rosa) presenting a study that debunked the claims of TT practitioners in a simple study where twenty-one practitioners of therapeutic touch failed to detect her aura (Rosa et al, 2009). TT is then, complete mystical woo-woo, and fails to meet any test of scientific credibility in that 1) the underpinning theory is tautological nonsense, and b) practitioners can demonstrate no efficacy better than placebo. No respected university will touch TT practical training with a barge pole. Nevertheless, we should note it is a highly profitable enterprise  (the overheads are minimal) and many nurses do support it. The professional regulator would seem to have some responsibility to ensure practitioners are using evidence-based practices, and TT (based on current evidence) clearly falls outside that scope.

The Outcome

Anyhow, in the end the CRNBC disposition on this case earlier this year sided with the practitioner, and that they were perfectly entitled to use their RN credentials to market their TT business as they found that:

a) the regulations are not intended to apply to RNs providing education services. The CRNBC regarded this registrant as providing an educational service, as the website identified was aimed at a TT consultation service.In other words they viewed an educational service as not being a product (even though it was a commercial, for-profit enterprise)!

b)  Alternative and complementary therapies are considered within the realm of holistic nursing.

Given the CRNBC’s position on CAM in general, I was not unduly surprised with this outcome, but am concerned this represents a particularly troubling precedent as point a) represents a very narrow view of what a commercial product is, and also implies you can sell health education on anything (whether good or bad) and simply tag your RN credential to your marketing materials. Point b) is even more worrying as it represents an “anything goes” approach to the regulation of RN practice (as long as you don’t physically hurt anyone; it’s all good). This completely ignores the responsibility to make sure practitioners don’t financially or emotionally exploit the public, and tarnish the reputation and credibility of the nursing profession.

Let’s examine a comparable example. If I want to promote my business as a tarot or astrology based health practitioner, and make good money selling my advice and education to the public who believe in this. Then I can tag on my RN credential to give it an air of professional respectability, better market my magical consultation services and improve my profits. Its all good!

I can’t help but ask; how does this approach protect the public rather than the profession? The finding here does nothing to protect the public from exploitation, and seems to give carte blanche for RNs to practice magic. To illustrate this, I have just acquired a practising Witchdoctor (WD) certification from the Canadian Association of Witch Doctors (it was a tough program, and examination I can tell you)! So, with my new magical powers, apparently using my title in the following advertisement is perfectly within my scope as an RN:

Loco Advert

Click here to see the full size Locomatic Energy Inc Advert

This advert covers the same ground as the website I originally made my original complaint against (well, apart from the cat, services being free and the windsurfing). The use of the RN title to support this sort of activity is clearly nonsense, and to be frank, supporting it is a travesty of regulatory practice and represents an example of where our professional regulatory body is failing miserably. Regulators traditionally err on the side of caution, remain impartial, and represent the public interest, not those of the professionals they regulate. In this case I would argue they clearly failed to meet their regulatory obligations in this respect.

Other nursing and health professional regulators I have observed seem to do a much better job in this area. The College and Association of Registered Nurses of Alberta (CARNA) Standards on CAM, 2011 notes:

“Registered nurses cannot use the title ‘RN’ or ‘NP’ in association with the endorsement or promotion of products or services. Endorsement of a product or service occurs when a nurse uses their credentials to lend credibility to a commercial product or service (CNO, 2009). The endorsement of a product or service without providing information about other options could mislead the public and may be considered a conflict of interest.”

Likewise the College of Nursing of Ontario, Professional Misconduct Regulations, 2014 states:

“It is not acceptable for a nurse to use her/his registration status to promote personal interests such as commercial products or services. Endorsement occurs when the nurse inappropriately uses her/his credentials to lend credibility to a commercial product, product line or service. The endorsement of a product line or service without providing information about other options has the potential to mislead the public and compromise trust.”

Both clearly indicate services (such as educational consultation) are to be treated the same as products in this respect. In the UK, The Nursing and Midwifery Council Code of Conduct 2014, is similarly clear, requiring practitioners to:

  • not abuse your privileged position for your own ends.
  • ensure that your professional judgement is not influenced by any commercial considerations.
  • uphold the reputation of your profession at all times.
  • ensure that the use of complementary or alternative therapies is safe and in the best interests of those in your care.

The College of Surgeons and Physicians of BC are also much clearer on how we should consider CAM in respect to public healthcare:

“Practitioners must not misrepresent the safety or efficacy of any therapy or procedure.”

“Complementary and alternative therapies differ from conventional medicines because they are generally unproven. When an alternative treatment undergoes rigorous testing, for example in a controlled and randomized trial, then the results dictate whether the alternative treatment becomes conventional treatment, whether the unorthodox becomes accepted, and whether the unproven becomes proven. Assertions, speculations, and testimonials do not substitute for scientific evidence.”

I did briefly pursue this CRNBC disposition on this case with the BC Health professional Review Board (HPRB), but have dropped it, as there is really nothing they can do in such a case as the HPRB are focused on interpretation of process and the law and are very unlikely to intervene in what they see as “professional jurisdiction” unless there is clearly evident harm arising. Astonishingly, it appears guidance published in CRNBC newsletters and advice has no real legal grounding anyhow, so can be completely different from interpretation of the actual standards by the disciplinary board. This doesn’t seem to reflect a well coordinated organization to me though. So, my next action is another formal approach to the CRNBC (I have raised this issue with them before) requesting they review their regulations and toughen them up in this respect.

Finally, although TT is generally harmless, we should be reminded these are serious concerns and not the trivial issues they are often taken as. Firstly, financially exploiting vulnerable people is a serious issue. Secondly, where the public are advised to consider alternatives to conventional evidence-based treatments, life-threatening results occur, as exemplified by the recent cases of the parents of two children with acute leukaemia seeking CAM remedies, and with people being advised to take homeopathic vaccines rather than actual vaccines. If we continue with this  approach to regulation and CAM practices, and allow them to be marketed with implied professional support, sooner or later deaths or injury will result from people In BC choosing CAM over medical alternatives on the advice of a nurse using their professional title to support their CAM practice. Effective regulation can help prevent this.

So, are nurses in BC licensed to practice magic? What do you think…

Bernie

References

American Cancer Society (2012) Therapeutic Touch.  Retrieved 20 October 2014.

Hewitt, P. 2007. Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century. London: H.M. Stationary Office

International Council of Nurses (2014). Regulatory Board Governance Toolkit.  http://www.nurse.or.jp/nursing/international/icn/report/pdf/2014m/04-04.pdf. Retrieved July 29, 2014.

O’Mathúna, D. N. P.; Ashford, R. L. (2012). O’Mathúna, Dónal P, ed. Cochrane Database of Systematic Reviews (Online) 6: CD002766

Rosa, Linda; Rosa, E; Sarner, L; Barrett, S (1998). “A Close Look at Therapeutic Touch”. JAMA 279 (13) 1005–10

Stenger, Victor (1999). “The Physics of ‘Alternative Medicine’ Bioenergetic Fields”. The Scientific Review of Alternative Medicine. 3(1) 79-84

Walsh, P. 2012. “Health Professional Regulation.” AvMA Medical and Legal Journal 18(3): 3–4.

World Health Organization (WHO). 2002. Nursing and Midwifery: a Guide to Professional Regulation. Cairo: WHO Publications Eastern Mediterranean Regional Office.

Other Relevant Sources

1. The CRNBC has a self-identified mandate to “protect the public through the regulation of registered nurses and nurse practitioners: https://www.crnbc.ca/crnbc/Pages/Default.aspx

2. Registrants are required to use their title(s) in ways that comply with the: CRNBC Standards of Practice. See: https://www.crnbc.ca/Standards/Lists/StandardResources/343AppropriateUseofTitlesPracStd.pdf

3. CRNBC October 2013 case study “Can she use her RN title?” which was subsequently amended – current version is at: https://crnbc.ca/Standards/resourcescasestudies/beinganurse/selfemployment/Pages/marketing.aspx .

Open Access Science and the Rise of Predatory Publishing

Following our summer hiatus from the blog Roger and I thought we would kick off this academic year with a piece on the changing nature of peer review and science publishing.

Like most professors we are finding our mailboxes more and more full of academic spam. If it is not companies trying to sell me transgenic rats, monogrammed lab coats in stylish colours or bioassay systems, its now invitations to present papers at conferences in exotic locations or publish with new journals I have never heard of (and usually well outside of my discipline). It’s enough to make me long for the days when I simply won the Nigerian state lottery a couple of times a week.

New technologies have arisen that now allow academics to publish more directly than ever before. Traditionally scientific work has been presented to the world for consideration of its merits and for challenge. The principle being that ideas and claims are independently examined, become refined, and bad ones rejected. This is a central part of the skeptical nature of scientific inquiry and remains a firm part of academic training, with PhD. candidates being required to defend their theses in robust discussion with their peers.

The peer review process for scientific papers prior to publication is an embodiment of this principle. The value is that the process is self-critical, and the conventional wisdom is consistently challenged. Modern science is pragmatic in that it presents ideas for peer review and openly invites opportunity for anyone to challenge the dominant theory if they can come up with alternative results or better explanations supported by evidence. Nevertheless, we know this culture is not value free as we have discussed previously, and there are costs associated with the dissemination of scientific information that are traditionally passed on to the end-user. Hence, the large publishers tend to be driven more by circulation and sales goals rather than more altruistic motivations, especially with books. For example, you can have an innovative well written book but still get it rejected by major publishers as it goes against the flow and is considered unlikely to sell in any volume. Despite their expertise and peer-review systems publisher’s often still get this spectacularly wrong (J.K. Rowling being a case in point in the world of fiction)! If we look at the number of retractions in scientific journals too, we also see some evidence of flaws in this traditional system.

So, with the advent of desktop publishing and mass circulation using the web, alternative models for dissemination have now arisen in all forms of academic publishing. Open access (OA) is one such innovation, and supports unrestricted online access to peer-reviewed scholarly research. A declaration on the principles behind OA were made at a 2003 Berllin Conference.  Although primarily intended for scholarly journal articles,it now also encompasses a growing number of theses, and book chapters too.This is hardly new though, and John Brockman noted there was a culture, of scientists communicating directly with the public about their work in media back in 1995 (Brockman, 1995). Nevertheless, the ideas behind OA publication reflect a desire to provide faster and more open access to scientific work.

Basically OA comes in two flavours, gratis open access, which is completely open and free online access, and libre open access, which is free online access plus some additional usage rights. These additional usage rights are often granted through the use of various licensing agreements such as Creative Commons. Authors have two options with OA publication. They can either  self-archive their papers in an open access repository, also known as “green” OA, or publish in an established OA journal, known as “gold” OA. Central repositories such as PubMed Central are examples of green OA, whilst gold OA usually use a fee-for-service model that tends to range from $1000 to $3000 per paper (depending on the open journal). This is justified on the basis of the editorial support and peer-review services involved in the publishing process.

Struggling academics looking to raise the profile of their work are often encouraged to use OA services to increase their citation rates (I have been advised of his on several occasions in my career), and some granting agencies require OA publication in any proposals submitted. So, overall there is growing pressure for academics to use these new publishing models, and gold OA seems to offer a robust peer-review process on a par with established traditional journals.

However, what is becoming more concerning is that the fee-for-service model has become a boom industry and entrepreneurs have recognized good money can be made here. This has led to the rise of the predatory publishing tactics which we are now seeing. The term was conceived by University of Colorado Denver librarian and researcher Jeffrey Beall upon noticing the large number of emails inviting him to submit articles or join the editorial board of previously unknown journals. Here is a classic example from my mailbox last week:

Pharmacology and Alternative Medicine Therapeutics

Dear Dr. Garrett,

Scholoxy Publication‘s journals are International Journal of Education and Research welcomes and acknowledges high quality theoretical and empirical original research papers, case studies, review papers, literature reviews, and technical note from researchers, academicians, professional, practitioners and students from all over the world.

We coordinately invite you to submit your papers to Pharmacology and Alternative Medicine Therapeutics an Open Access (Gold OA), peer reviewed, international online publishing journal which aims to publish premier papers on all the related areas of advanced research carried in its field.

The Journal has strong Editorial Board with eminent persons in the field and carries stringent peer review process.

It all sounds very genuine and scholarly, apart from the fact I don’t know anyone in the pharmacology department who has heard of them (in a positive way), and I am not even a pharmacology or alternative medicine professor! This unsolicited invite is actually from a pay-per-publication service whose peer-review process is completely unverified, and I am certainly a little suspicious as to how “stringent” the peer review process is when each publication is accompanied by a cheque.

More subtly these new publishers are also engaging academics to join their editorial boards, or become reviewers on their prestigious journals. Another tactic reflecting these practices is the use of what seem like personal invitations to present at conferences (in reality they are mail-merged bulk mailings to spam lists). To highlight these issues, I see the Canadian Association of Witch Doctors recently submitted and got a spoof paper approved at one such peer-reviewed  OMICS conference. Again, for academics beginning their careers (or even established academics) these may seem like great opportunities to develop their profiles or get their work to a broader audience.

So how can we discern the predatory publishers from genuine scholarly OA providers? Luckily, there are some resources that can help.Jeffrey Beal provides an extensive list of dubious OA outfits on Scholarly Open Access. Worth a look as it’s amazing how many there are!

There are also several sites that provide journal rankings, so academics can check out the status of their chosen journal. E.g., in my discipline (nursing) there are the following examples:

Many disciplines also have lists of established journals in their field, such as INANE’s list of nursing journals. However, even these lists are not foolproof in terms of establishing the academic credibility of journals. For example  Nursing Science Quarterly (incredibly still published by Sage – note my earlier comments on publishers motives) makes several of these lists and although not a predatory publication, is hardly a paragon of scientific excellence, self-citation or rigerous peer-review practices. I think Roger would see this one fit his “isn’t that like asking your mum to review your papers?” category.

Overall, the rise of predatory publishing and how it will impact the broader scientific community and influence the public understanding of science is something of a concern. It seems the best advice for scientists everywhere is buyer beware. There is nothing wrong with traditional journals, and we should remember there are a good many reputable OA journals. However, the usual practice is you send them a paper: not you receive an invite from them. Sometimes good journal editors do solicit work from established researchers and theorists in the field. But, if an offer comes your way to join an editorial board, present at a conference or publish in a venerable new journal and it seems too good to be true, it probably is.

Onwards and upwards

Bernie

References

Beall J. (2012) ON Predatory Publishers http://chronicle.com/blogs/brainstorm/on-predatory-publishers-a-qa-with-jeffrey-beall/47667 

Brockman, J. (1995). The third culture. New York: Simon & Schuster