McGill Journal of Law and Health

Contributed by Jacob Shannon

Introduction

Nurses throughout the province of Quebec understand their role through the Nurses Act. Article 36 names 17 reserved practice areas for nurses centred around assessing and monitoring health. These reserved acts do not include the competencies to diagnose illness, prescribe medication, and perform invasive tests. These acts are instead separated off for specialized nurse practitioners and are enumerated instead in Article 36.1. However, my experience as a “rôle élargi” (RE) nurse told a different story of nursing, one that is out of step with the Nurses Act and points to a double standard in healthcare for Canada’s rural Indigenous communities.

What is Rôle Élargi Nursing?

Nurses working in Indigenous communities in rural northern Quebec can follow an advanced training to become an RE nurse. This training is available to nurses who have worked for more than two years in an acute care speciality and is not encompassed by the Nurses Act or any other provincial legislation. The training is offered directly by health boards and nursing placement agencies and is not supervised by the government or the Order of Nurses of Quebec (OIIQ).

Neither CEGEPs nor universities in Quebec are subject to regulation on how they educate their student nurses. However, many universities seek accreditation from the Canadian Association of Schools of Nursing, which lists specific standards nursing schools must abide by. As with standard nursing formation, the RE training process is left up to institutional discretion, but unlike with standard nursing formation, no accreditation process is offered to health centres and agencies providing RE training. A report by the OIIQ inquiring into the needs of RE nurses highlights at page 13 that these nurses themselves believe that minimum requirements must be enforced on their formation.

After two years of working in a Pediatric Emergency Department and desiring to work with Indigenous patients on their homelands, I turned to one of these formations offered by a nursing placement agency. My training lasted five weeks: I learned to diagnose certain conditions, prescribe limited treatments, and discharge my patients at the end of our encounter. These tasks would be based on collective orders issued by the health centres for which I worked, but I could not help but feel that such a short training was insufficient for the powers it conferred.

What are Collective Orders?

Before understanding the work of an RE nurse, it is important to understand collective orders. Prescribing medication falls under the reserved acts of doctors and nurse practitioners [hereinafter referred to as providers]. Despite this being a reserved act, there are situations where collective orders issued by health centres may delegate the task to nurses. Modifications to Article 39.3 of the Quebec Professional Code Act in 2002 expanded this delegative power by removing limitations on the types of orders that could be delegated.

Collective orders, also known as standing orders, are a form of always-available prescription issued by a health centre or one of its departments so that nurses can act without a provider’s order. A classic example of a collective order is the delegated ability of nurses to administer fever-reducing medications such as acetaminophen for patients presenting with fever to triage of an emergency room.

Nurses performing emergency department triage are competent to diagnose fever as a part of their assessment, and the best course of action is to allow them to immediately treat it. By facilitating the ease of administration of fever-reducing medications, hospitals may alleviate suffering while patients wait to be seen by a provider who can prescribe them a much larger litany of treatments. The prescription doesn’t pose much risk if it is correctly followed, but the benefit to both the patient and the health centre is high. RE nurses have access to a much larger list of delegated powers, including ones that are not as low risk as the example above.

The Therapeutic Guide: A Broad Use of Collective Orders

Collective orders that may be executed by RE nurses are laid out in a therapeutic guide, organized by the different bodily systems. The guide stretches the limit of what can be considered a collective order by attempting to provide comprehensive and ready-made assessment and treatment plans for common illnesses. This plan often includes tests and treatments that must be prescribed by a provider under normal circumstances but are instead provided for in broad collective orders and left to the RE nurse’s discretion. For example, nurses can turn to the dermatology section to prescribe a range of corticosteroid creams, the respiratory section to prescribe oral antibiotics or inhalers, or the emergency section to prescribe and immediately administer a dose of epinephrine in a case of anaphylactic shock. Some of these treatments come with risk, and most are not available over the counter.

The logic behind the collective order, delegation of an act not normally within a nurse’s scope, is similar in both the RE setting and the standard healthcare setting, but its application is not. In both cases the collective order reduces patients’ wait time to receive tests and treatments, but that is where the similarity ends. In a standard healthcare setting, the collective order is meant to administer a test or treatment to the patient early in care before they have seen a provider. Collective orders in the RE setting delegate entire treatment plans instead of specific tests or treatments, and the nurse may directly discharge their patient at the end of the consultation without a provider’s involvement.

Power of Disposition: Discharge Home

The power of discharge has the potential to give rise to significant liability and is generally carried by physicians, and more recently by nurse practitioners. Nonetheless, the therapeutic guide also awards the power of discharge to RE nurses. After evaluating their patient and prescribing tests and treatments provided for in the guide, an RE nurse may discharge their patient once they confirm that there are no indications specified in the guide to refer to a provider.

This isn’t always true: certain cases must always be referred to a provider, notably in any situation where a patient presents acutely unwell. Subtler distinctions also give rise to referrals. For example, a patient with fever can be discharged by an RE nurse if they are over one year of age but must be referred to a physician if younger. Similarly, patients with urinary tract infections may be treated with antibiotics selected by an RE nurse through the guide, but only if they are not diabetic. These subtle distinctions are an area of potential error for a nurse using the collective orders the guide contains.

In cases where there is no indication to consult a provider, a patient will generally receive their discharge from the RE nurse. Although nurses may, and are encouraged to, refer cases to a physician if they are unsure about the diagnosis or treatment, there is no official mandate to do so in every case. RE nurses thus find themselves operating in a grey area that may go beyond the intended scope of their role; collective orders are not used to provide comprehensive treatment plans, including discharge to patients, in similar settings located outside of these northern regions.

Different From Standard Clinic Practice

It’s understandable that rural clinics must operate differently than clinics in urban centres. But even after accounting for the differences, there appears to be a double standard between how Quebec regards nursing care in the rural north and how it is in the urban south.

The double standard is visible when patients in the largely Indigenous regions of northern Quebec see nurses instead of providers for their walk-in concerns. Contrast this to the south of Quebec where seeing a provider is the standard of care. The double standard is even more apparent outside of clinic hours, where no options exist for twenty-four-hour walk-in care in the small communities of northern Quebec. Instead, patients requiring overnight care must call the clinic phone, where a nurse determines whether the case is urgent or can be deferred to the daytime. This stands in contrast to standard of care in the rest of the province where patients who desire assessment in an emergency department will infallibly receive an in-person triage, even if their wait time to see a provider may be long.

The RE program was implemented to increase healthcare availability for patients that had even less access before the program existed. Still, the double standard would not survive public scrutiny if RE nursing was to arrive today in Quebec’s urban health centres. Patients would still expect to see providers for their health issues and would be outraged if any limitation was placed on their ability to self-present to an emergency department. Regardless of its origins, the RE program enacts two standards of care within the same healthcare system. There is no justification why residents of rural northern Quebec, who are overwhelmingly Indigenous and suffer from more health issues per capita, should receive a different standard of care than urban Canadians.

Conclusion

For three years I performed RE nursing to the best of my abilities. For the entirety of that time, the double standard weighed on me. The future of healthcare for Quebec’s Indigenous communities need not be married to the double standards that exist today. It should instead be founded on the same scopes of care that exist throughout the province.

Rather than attempt to create a new profession, it instead makes more sense to take recourse to an existing one to meet a similar need. Nurse practitioners are already filling much needed gaps present in our healthcare system and providing relief to patients from long waiting times. Nurse practitioners follow a four-year master’s degree, as opposed to the five-week RE training, and are legally empowered to perform the acts necessary to fill treatment gaps that exist in the north. Most importantly, nurse practitioners would be practising under the same scope and legislative framework that they are already entitled to practice under, sans delegative gymnastics.

Rather than permit the delegation of entire treatment plans, which stretches the collective order beyond its purpose, the governments of Quebec and of Canada should put forward additional funding to send more providers into rural Indigenous regions and double down on efforts to train more nurse practitioners. This will not come at a small cost, but it is the cost necessary to eliminate the double standard and make real progress on reducing health inequity for our Indigenous neighbours to the north.

About the Author

Jacob Shannon is the Executive Online Editor of the McGill Journal of Law and Health. He is currently in his second year of the BCL/JD program at McGill University’s Faculty of Law. Before starting law school, Jacob worked as a Nurse Clinician at the Montreal Children’s Hospital Emergency Department and as a Rôle Élargi Nurse in the Cree communities of Whapmagoostui, Waskaganish, and Mistissini.