Practice Expectation Spotlight: Entry-Level Competencies for RN(NP)s

As part of the five year renewal cycle, the Canadian Council for Registered Nurse Regulators (CCRNR) refreshed the Entry Level Competencies (ELC) for a new model of Nurse Practitioner regulation in Canada. This was a concerted effort by nursing leaders, RN(NP)s, RN(NP) educators and the public who contributed through surveys and together created a revised version of the entry level competencies for nurse practitioners in this country. The process began in 2020 with over 10 jurisdictions participating. https://www.ccrnr.ca/npr-fipp.html

Specifically, this change assists Regulators, Employers, and Registrants to better understand the role of RN(NP)’s and the following examples are but a few of the ways ELCs are used.

Practice advice / guidance to clinicians 
Reference for professional conduct matters & human resources 
Use in regulatory processes

Objective: The purpose of this article will demonstrate how an RN(NP) can evolve their role of advocacy for Indigenous People through examining and challenging unconscious bias. The role of advocate for indigenous people has been revised and the section for the discussion of this article is 3.1 practice self-awareness to minimize personal bias based on social position and power. It will briefly comment on addressing how regulatory or conduct matters may be applied to practice of RN(NP)s, so that they are following this newly revised role.

Background

Research has determined that we are all, as human beings, biased in some respects. We bring our own personal perspective to the task of decision making. This is the wellspring of what we call “common sense” (CNAR, 2022). However, it is also a repository of unproven fact, intuition, conjecture, inherited wisdom, experienced trauma, and other mental baggage we carry. We are encouraging RN(NP)’s to find and engage in training specifically on unconscious bias. Through this examination, our hope is to encourage practitioners to acknowledge and then put aside any assumptions or preconceptions they may have when they’re assessing an indigenous client(s) or dealing with their families. As in the example of Dr. Nittri from Ontario – the decision of Ontario’s HPARB in 2020, found this physician culturally unprepared to appropriately address an indigenous client. Read more here (and for an article about this case, see here).

How can RN(NP)’s advance in the role of advocate as cited in newly revised entry level competencies. The following responsibilities have been taken out of the newly revised ELCs and are given to the graduate of advanced nursing practice and will be applied to practicing RN(NP)s:

3.1 Practice self-awareness to minimize personal bias based on social position and power.

Demonstrate cultural humility and examine assumptions, beliefs, and privileges and challenge biases, stereotypes, and prejudice
Address the effects of the unequal distribution of power and resources on the delivery of services
Demonstrate respect, open, and effective dialogue, and mutual decision-making
Evaluate and seek feedback on own behavior

Practical application of Entry Level Competency in Practice

Along with reviewing the CRNM’s interprofessional collaboration practice direction, a RN(NP) can question unconscious Bias. From a CNAR conference (October 24, 2022), here are some tips from A. Armstrong et.al (2022):

Tip 1. Find internal motivation. Motivation to reduce implicit bias aids a person’s ability to do so.

Tip 2. Be self-observant and self-critiquing. Be comfortable with this uncomfortable process.

Tip 3. Don’t just ask why you don’t like someone. Ask yourself why you do like someone?

Understanding how positive and negative associations work and acknowledging that on a regular basis is important.

Tip 4. Remind yourself of your own unconscious biases. People who believe that they are unbiased often are not.

Tip 5. Seek out different viewpoints. Diversity of opinions will not only improve the quality of decision making it will also act as a check and balance on unconscious bias.

Tip 6. Make your self uncomfortable be open to uncomfortable conversation. Don’t be afraid or defensive when bias is challenged. Embrace opportunities to learn and grow.

Tip 7. Avoid jumping to conclusions based on personal likes or dislikes, generalizations, gut feeling, prejudices, sympathies, or stereotypes.

Professional conduct matters

When providing care, an RN(NP) is required to demonstrate that they have met the practice directions of an RN and RN(NP). An RN (NP) who provides biased care may not be meeting the practice directions. As in the case with Dr. Nitti who was found to be culturally insensitive to the indigenous child she was caring for in the Emergency Department in Muskoka Algonquin Health Centre she was unconscious to her own biases. The CPSO committee identified two areas of practice where Dr. Nitti would benefit from further cultural education, “noting that there was nothing to suggest that the concerns were not capable of remediation. The Committee addressed its identified concerns by means of a remedial agreement and stated its expectation that physicians “communicate sensitively with all patients and family, including those of a culture other than one’s own”. 

Regulatory processes

The regulatory process is guided by entry level practices and as such the ELC document sets the requirements of RN(NP)s in clinical practice. As these changes are implemented, practice is impacted because consciousness of the new role of advocacy for RN(NP)s is more defined and specific to include cultural safety for Indigenous People.

Conclusion

The newly revised role of advocacy for RN(NP)s demonstrates how to evolve this role continuously during a nursing career. Tips for understanding one’s own unconscious bias are just the start of ongoing and continued vigilance to counteract such bias. ELCs are the beginning point in a career path. RN(NP)’s are known for delivering high-quality, client centred care. These competencies will be brought to the College of Registered Nurses of Manitoba Council in March 2023 for review and decision into RN(NP) practice.

References

A.D-S v N.M.N., 2020 CanLII 67103 (ON HPARB), <https://canlii.ca/t/j9nzl>, retrieved on 2022-11-24 2020 CanLII 67103 (ON HPARB) | A.D-S v N.M.N. | CanLII

A. Armstrong, & Presenter, D. McKenna, L. Kinkartz, (2022, October and 24). Pre-Conference Workshop Unconscious Bias: What decision-makers need to know. [Guest speakers]. CNAR, Charolettetown PEI.

CCRNR (2022) Entry level competencies for RN(NP) https://www.ccrnr.ca/npr-fipp.html Nurse practitioner regulation framework implementation plan project.

CRNM Interprofessional collaboration care practice direction (2022) https://www.crnm.mb.ca/wp-content/uploads/2022/01/Interprofessional-Collab-Care_aug30.pdf

Conduct Department (2022, November 4). Consultation on Entry Level Competencies revision. [Personal Communication]. CRNM, Winnipeg, MB.

Moore, H. (2020) Retrieved online on November 24, 2022 Health board orders new review of doctor’s genital examination on child (aptnnews.ca)