April 17, 2015 Ms. Lynsay Nair, LPN Executive Director Saskatchewan Association of Licensed Practical Nurses 700A - 4400 4th Avenue Regina, Saskatchewan S4T 0H8 Dear Ms. Nair: Please find attached written responses from the Saskatchewan Union of Nurses (SUN) in response to the Proposed Amendments to the SALPN Regulatory Bylaws, 2015, currently posted on the SALPN website, as well as the draft Decision Making Framework and draft Practice Guidelines. These written responses cover three areas:

Draft Bylaw Amendments As a nursing regulator with the primary mandate of public protection, the SALPN must ensure several key principles are followed when considering bylaw changes affecting nursing care delivery. In the attached document, SUN lays out continued concerns with the Bylaws and Specialized Practice Areas as currently written. Draft Decision Making Framework The Draft “Decision Making Framework – Quality Nursing Practice” circulated by the SRNA, the RPNAS, and the SALPN represents an important first step in supporting effective collaboration among nursing care providers. By emphasizing the key principles of collaboration and consultation, and by placing these on a continuum of care requirements based on client, nurse, and environmental factors, the Framework provides an important building block for supporting effective decision-making and collaboration. Elements of the framework require considerable elaboration and clarification in order to provide the necessary support to appropriate decision making. Consistent with the “Guiding Principles,” the Framework must make clear reference to the education, legislated scope of practice, and the distinct roles and responsibilities of nursing care providers in the process of assigning, coordinating, and delivering patient care. In the absence of these specifications, the Framework will not address the issue of role clarity and support appropriate decision making in an effective and sustainable manner.

Draft Practice Guidelines The draft Practice Guidelines that accompany the proposed SALPN bylaws raise many concerns regarding patient safety, role clarity and ability to implement the content into the practice environment in a consistent, cohesive manner. This information does not provide any evidence, or refer to any valid research, supporting that LPNs as currently educated have the foundational knowledge to ensure safe performance at the level of functioning described.

We would also like to identify that we have not received a response to questions and concerns posed in our original submission to you of January 2015, nor our amended submission of March 2015. Therefore, we would appreciate your response to concerns raised in all of our submissions prior to your Annual Meeting. Thank you for your prompt attention to this matter. Sincerely,

Donna Trainor RN Executive Director cc Tracy M. Zambory RN, President, SUN

Amber Alecxe, Director, Patients and Families First & Government Relations, SUN Kelly Miner, Director of Labour Relations, SUN Honourable Dustin Duncan, Minister of Health, Government of Saskatchewan Tracey Smith, Assistant Deputy Minister, Ministry of Health, Government of

Saskatchewan Cole Shulz, Chief of Staff, Minister of Health, Government of Saskatchewan Max Hendricks, Deputy Minister, Ministry of Health, Government of Saskatchewan Duane Mombourquette, Executive Director, PWPB, Ministry of Health, Government of

Saskatchewan CEOs & VPs HR, Regional Health Authorities Signy Klebeck RN, President, Saskatchewan Registered Nurses’ Association Linda Wasko-Lacey RN, President-Elect, Saskatchewan Registered Nurses’ Assocation Karen Eisler RN PhD, Executive Director, Saskatchewan Registered Nurses’

Association Marion Palidwor RPN, President, Registered Psychiatric Nurses Association of

Saskatchewan Syd Bolt RPN, President-Elect, Registered Psychiatric Nurses Association of

Saskatchewan Robert Allen RPN, Executive Director, Registered Psychiatric Nurses Association of

Saskatchewan Pauline Mason, President, Saskatchewan Association of Licensed Practical Nurses Kari Pruden, President-Elect, Saskatchewan Association of Licensed Practical Nurses Barbara Cape, President, SEIU West Gordon Campbell, President, CUPE Healthcare Council of Unions Bob Bymoen, President, SGEU

Review and Analysis - April 2015 SALPN BYLAWS

The Saskatchewan Union of Nurses

As a nursing regulator with the primary mandate of public protection, the SALPN must ensure several

key principles are followed when considering bylaw changes affecting nursing care delivery.

That regulatory bylaw creation is supported by the LPN Act and is consistent with the

foundational education that forms the basis for the scope of practice for LPNs.

That nursing research, evidence and national best practice standards guide decision-making.

That changes to nursing practice rest on clear rationales and demonstrated need.

That changes to nursing practice are supported by mandatory formal post-basic education.

That specialized areas of practice clearly differentiate between the roles of LPNs and RNs/RPNs

That specialized areas of practice and any additional endorsed activities are undertaken in

consultation and/or under the supervision of a RN or RPN, consistent with their legislated role

in the coordination of nursing care

Concerns with all Specialized Practice Areas as currently written

Little or no evidence that areas are consistent with LPN education or that proposed post-basic

education actually supports the level of functioning described in the Practice Guidelines

Research, evidence and best practice is not cited to support the proposed practice area

Client condition and need are not identified or considered as determining factors for LPNs

engaging in specialized practices

The reliance on Practice Guidelines that are not cited in bylaws to define role, scope, and care

functions creates uncertainty about what standards are being followed

The distinct roles and responsibilities of the LPN and RN are not acknowledged or defined,

contributing to role confusion

Perioperative

The bylaws and Practice Guidelines do not cite and follow ORNAC national standards

Hemodialysis

PLAR assessment is not required, leading to uncertainty regarding foundational knowledge,

competencies, practice standards, and patient safety.

Advanced Foot Care

No rationale or demonstrated need has been provided

Advanced Orthopedics

The role is currently performed by a professional group with national standards for education

and accreditation – the Canadian Society of Orthopaedic Technologists (C.S.O.T.) – which is

supported by Orthopedic Surgeons across Canada

The cited post-basic course from Norquest College is not accredited or endorsed by C.S.O.T

Comments on the Draft “Decision Making Framework – Quality Nursing Practice” The Saskatchewan Union of Nurses

A Step Forward

The Draft “Decision Making Framework – Quality Nursing Practice” circulated by the SRNA, the RPNAS,

and the SALPN represents an important first step in supporting effective collaboration among nursing

care providers. By emphasizing the key principles of collaboration and consultation, and by placing these

on a continuum of care requirements based on client, nurse, and environmental factors, the Framework

provides an important building block for supporting effective decision-making and collaboration.

Elements of the framework require considerable elaboration and clarification in order to provide the

necessary support to appropriate decision making. Consistent with the “Guiding Principles,” the

Framework must make clear reference to the education, legislated scope of practice, and the distinct

roles and responsibilities of nursing care providers in the process of assigning, coordinating, and

delivering patient care. In the absence of these specifications, the Framework will not address the issue

of role clarity and support appropriate decision making in an effective and sustainable manner.

Client Factors

Decision making regarding the utilization of RNs/RPNs and LPNs is informed by the complexity,

predictability and risk for negative outcomes involved in a client care context. The decision making

framework must clearly define these terms and provide guidance on their application in the clinical

setting. Tools such as the “Patient Care Needs Assessment (PCNA)” provide scientifically validated

methods of determining the needs of the client and matching patient assignments to provider

knowledge and competencies.

Nurse Factors

The breadth and depth of formal education and foundational knowledge/ competencies – as the basis

for the scope of practice of different providers – must be included among the “factors that affect a

nurse’s ability to provide safe and ethical care to a given client”. Education and scope of practice are

among the most important “nurse factors” that must inform decision-making about appropriate

assignment of care. Collaboration and consultation must be based on respect for “the unique

contributions and abilities of each member.” The distinct education and scope of practice of providers is

among the most important elements of their “unique contributions and abilities” and must be included

in the Framework.

Distinct roles and responsibilities

The Draft Framework does not provide adequate guidance to decision-making regarding patient care

assignment, the transfer of patient care functions, or the coordination of patient care. Specifically, it

does not adequately reflect the distinct roles and responsibilities of the RN/RPN and LPN in the

coordination and assignment/transfer/delegation of care.

The Draft Framework acknowledges that the assignment of clients and client care functions must be

based on the three factor framework, but it does not contain any guidance on how that assignment is to

be made and the different roles and responsibilities of different nursing care providers related to

assignment. This is a very serious omission that will have to be clarified in order to support appropriate

decision-making in actual practice settings based on clear roles and responsibilities.

For example, the Framework identifies that all nursing providers may practice autonomously where

client needs are less complex, more predictable, and have a low risk for negative outcome(s). The

Framework identifies that, in the context of LPN care, as client needs become more complex, three

possible outcomes are possible: (1) the LPN “receives RN/RPN advice and continues to care for client”;

(2) “Some aspects of care are transferred to RN/RPN”; (3) “All care is transferred to the RN/RPN”.

The Draft Framework provides no guidance regarding responsibilities for overall assessment and the

determination of client status and appropriate patient assignment prior to determining which nursing

care provider has the competencies to provide the required care. Clear guidelines that identify

appropriate actions if/when care needs have become more complex or less predictable requiring that

some or all aspects of care are “transferred” to the RN/RPN are needed.

Clearly, it is important to ensure that an appropriate approach is used to assign clients and/or care

functions and to clarify responsibilities related to assignments. LPNs organize and deliver care for less

complex and more predictable patients on the basis of an established care plan. RNs and RPNs lead and

coordinate the care planning process and give clinical guidance, while LPNs collaborate and contribute

to the care planning process. Recognition of this distinction in roles and responsibilities must be

incorporated in any decision-making Framework.

It is ultimately the role and responsibility of the RN/RPN to make an overall assessment of client

status, to determine the appropriate assignment or reassignment of client care functions, and to

provide clinical guidance as part of their legislated responsibility for the coordination of nursing care.

Even where RNs, RPNs, and LPNs have been trained to perform similar specific tasks or functions, the

depth and breadth of education with respect to clinical knowledge and judgment is very different. This

must be reflected in the decision-making framework.

Collaborative nursing practice requires that individual providers see themselves as part of a team,

working together based on a shared mission to provide safe, appropriate, and high quality patient care.

An effective and sustainable model of collaborative practice must be based on mutual recognition of the

distinct and complementary education and competencies of each provider, and on mutual respect for

their discrete roles and responsibilities.

Analysis and Review - SALPN 2015 Draft Practice Guidelines for Specialized Practice The Saskatchewan Union of Nurses

The draft Practice Guidelines that accompany the proposed SALPN bylaws raise many concerns regarding patient safety, role clarity and ability to implement the content into the practice environment in a consistent, cohesive manner. This information does not provide any evidence, or refer to any valid research, supporting that LPNs as currently educated have the foundational knowledge to ensure safe performance at the level of functioning described. The following sections highlight specific areas of concern with the current Practice Guidelines as written.

1. Hemodialysis Care: Specialized Area of LPN Practice Clients suffering from acute or chronic kidney impairment have complex and unpredictable care needs. Often clients with renal impairment suffer from other conditions such as diabetes, hypertension, cardiovascular disease, etc. Clients receiving care for kidney impairment are at risk for blood clots, bleeding complications, electrolyte imbalances, cardiac arrhythmias, amputation, infection, respiratory distress/arrest, shock, cardiac arrest and death. The proposed Practice Guidelines must clearly define the LPN role in Hemodialysis and differentiate it from that of the RN.

SALPN Practice Guideline Information Concerns

LPNs in the hemodialysis care specialized area are prepared with advanced education in the care of patients receiving hemodialysis

The basic education program for LPNs contains limited theory relevant to hemodialysis. Basic hemodialysis knowledge is obtained from employer education. There is no indication that this provides the foundational knowledge to support an advanced role in hemodialysis

The LPN will have the knowledge to perform competently and to utilize critical thinking and clinical judgment in decision-making related to kidney disease.

What level of decision making is the LPN responsible for? When would consultation with the RN need to occur? How is the role different than that of the RN?

SALPN recognizes successful completion of a post-basic education program, as approved by council, if completed prior to Jan, 2016

A PLAR process is required to determine if appropriate knowledge has been obtained in the varying “employer education courses”

SALPN will recognize a formal post-basic education certificate program from SK Polytechnic (or an equivalent) completed after Jan 2016

This is one course – it is not a “certificate program”. Content from this course needs to be evaluated for intent and application

“Peritoneal dialysis is a basic LPN competency” This is asserted without evidence.

Peritoneal dialysis, hemodialysis, transplant preparation, hypoxemia, exsanguination, chest pain, dysrhythmias etc.

The Practice Guidelines make no reference to the stability or predictability of clients as factors for LPN assignment.

2. Perioperative Care: Specialized Area of LPN Practice The perioperative setting is a complex environment with high risk for negative patient outcomes. Clients undergoing anesthesia and surgery are unpredictable by definition. Care providers with the appropriate foundational and post-graduate education must be available to provide safe client care, with clear roles based on accepted national standards. The recognized national standards are from the Operating Room Nurses Association of Canada (ORNAC). These standards are based on sound evidence and research and are highly regarded within the perioperative setting as best practice.

SALPN Practice Guideline Information Concerns

Practises pursuant to an order of an authorized professional and in collaboration with other members of the health care team

The presence of a physician’s order does not constitute authorization for a LPN to perform the order, or substitute for the coordination of care by a RN.

LPNs will perform the circulating or scrub role only when a RN is present in the primary circulating role and Section 4: Knowledge and application of circulating role

This is not in accordance with ORNAC standards, which are cited in the bibliography but ignored. The circulating role is a RN speciality role.

Observe and provide appropriate response to complications and unexpected events during the surgical procedure i.e., cardiac arrest, hypothermia

This is beyond the scope of the LPN – the patient is complex and unstable in these situations and requires care of the RN

Section 5: Knowledge and Assistance to the

Anesthesia Provider - Demonstrate critical thinking

and clinical judgment related to assisting the

anaesthesia provider in each of the following

competencies: Assist the anaesthesia provider with the administration of general anesthetic, epidural, spinal, topical, retrobulbar, local anaesthetics, and blocks Initiate intravenous and prepare supplies for anaesthesia provider Provide medication to the anaesthesia provider when requested Assist with induction of anaesthetic:

Intubation, fixation, and connection of

endotracheal tube

Cricoid pressure if necessary Assist with extubation and reversal of anaesthesia

This is beyond the scope of the LPN as supported in the ORNAC standards

3. Advanced Orthopedics: Specialized Area of LPN Practice Patients requiring advanced orthopedic care have experienced complex trauma. Patients experiencing fractures requiring setting of bones (including fractures of the spine requiring halo traction application) are at risk of complications such as blood clots, fat emboli, paralysis, compartment syndrome, loss of limb, hemorrhage and death.

SALPN Practice Guideline Information Concerns

The Practice Guideline does not address questions regarding foundational knowledge and supporting advanced practice with research and evidence as to outcomes

No indication is provided that the identified college course supports the “advanced” role described in the Practice Guideline.

Guideline identifies many of these procedures will be occurring “under conscious sedation”

Conscious sedation is a complex, high risk activity. Who will administer the conscious sedation and monitor the client? What foundational knowledge does the LPN have to take on this advanced role?

4. Advanced Foot Care: Specialized Area of LPN Practice Clients requiring advanced foot care are often afflicted with a complex disease process (diabetes, hypertension, peripheral vascular disease, etc.) and are at risk for negative outcomes. Clients with these types of conditions are highly susceptible to impaired healing and complications. If foot care is not done appropriately patients run the risk of experiencing significant pain, as well as loss of limb or function in response to infections, for example.

SALPN Practice Guideline Information Concerns

Successfully completed post-basic education certificate program in advanced foot care, known as the “Foot Care: Principles and Practice” from Saskatchewan Polytechnic or equivalent

The college course Foot Care: Principles and Practices (NURS1656) confines learning to common nail and skin pathology and assessment of the foot, and includes a two day lab where the participant will practice and demonstrate foot care, nail cutting, and basic padding techniques. The course description does not identify any learning focused on “complex alterations or variations of foot health as a result of pathology and/or disease,” “enhanced knowledge of anatomy, structures and functions of the nail, foot and skin,” “comprehensive assessments of lower extremities, and providing nursing interventions to address problems of the anatomy, structures, and functions of the nail, foot, and skin”. Procedures focused on removal of tissue (helomata and hyperkeratosis) and application of packing and utilization of the rotary drill do not appear to be included in the identified course.