Nursing Standard Setting andRegulation: Successes and

Challenges

Jean BarryConsultant, Nursing and Health Policy

International Council of NursesNairobi, Kenya, February 2011

International Council of Nurses (ICN)

• A federation of 134 national nurses associations (NNAs)

• Representing the more than 13 million nurses worldwide

• Three policy pillars: professional practice, socio economic and regulation

Regulation and Standard Setting

RegulationAll of those legitimate and appropriate means whereby order, identity, consistency, and control are brought to the profession.

Standards• A standard is a desired and achievable

level of performance against which actual practice is compared.

Purpose of Regulation

• The prime purpose is to protect the public from unsafe practitioners

• Safeguards patient safety by clarifying the competencies, qualifications and expectations for practice of nurses

Regulation• Should be efficient, effective,

transparent and fair• Requires professional

involvement • Profession is best able to identify

standards for education, practice and ethics required for safe, competent and ethical care

Regulatory Models

• Multiple models exist• A continuum from little or no

regulation - to administered fully within the Ministry of Health - to administered by a National Nurses Association - to arms length body (e.g. Nursing Council) enabled by government legislation

Regulatory Legislation• The legislation may stand on its

own (Nurse’s Act) or form part of wider multi-professional legislation (Health Professions Act)

• Globally, there is great diversity in regulatory frameworks and legislation and the legal systems on which they are based

• Legislation should be as flexible as possible to allow for responsiveness to changes

Standards and Standard Setting

Standards should be:• Meaningful, appropriate,

relevant, measurable and achievable

• Reviewed regularly and updated

• Engage nurses and the public in development and update

Regulation and Standard Setting

• Many stakeholders are involved in nursing regulation and standard setting– The individual nurse– The profession– Governments– Educational institutions– Employers – The public– Other health care professions

Core Functions of a Regulatory Body

• Setting standards for entry on the Register

• Establishing education standards and recognizing programs

• Establishing and promoting practice standards, requirements for ongoing competence and codes of ethics/conduct

• Enforcing standards of practice and conduct including carrying out conduct review or discipline

• Maintaining the Register

Other Roles for Regulatory Bodies

• Advocating for quality health care and healthy public policy in the public interest

• Working with others to address the need for practice environments that support safe, competent and ethical care

• Supporting a stable supply of nurses by informing health human resource planning with data collected through licensure

Challenges and Successes

Impacted by:• Globalisation• Health Human Resource

Shortages• Economic Downturn• Increased focus on regulation

and patient safety

Globalisation

Challenges• Increased mobility of professionals

resulting in even greater shortages in some regions

• Due to push for mobility and trade agreements - Increased intervention in regulation sometimes not in the public interest

• The mobile workforce highlights the diversity in regulatory models and requirements globally including the lack of regulation in some regions

GlobalisationSuccesses• Focus on mobility is resulting regional

and global dialogue and action among regulators and others (e,g, ECSACON, WACN, EFN)

• Communication and collaboration between regulatory bodies globally facilitates sharing of regulatory best practices

• Increased congruence in the development of local, national and international regulatory systems

GlobalisationSuccesses (continued)

Local - Multi-professional groupingsRegional– ECSACON Regulatory Framework, – European Union Directive 36– ASEAN Accord– Caribbean common exam– Middle Eastern countries collaboration on

the development of regulatory structures International– ICN, ICM, WHO and others competency

frameworks and guidelines– World Health Professions Alliance

Economic DownturnChallenges• Economic support to developing

countries who are in the process of system improvement is being impacted

• Multiple new groups of health care workers being introduced to the system – causing concern re competency, confusion re supervision and scopes of practice

• Significant cost cutting measures including lay-offs and hiring freezes with resulting decrease in the quality of care in many countries of the world –developed and developing

Health Human Resource Shortages

Challenges• Shortages of professionals with

resulting risks to patient safety and deterioration in quality of care

• Proliferation of private for-profit schools with insufficient oversight and graduates who are not practice-ready

• Nurses being pushed to practice beyond scope and without proper regulatory authorisations

Health Human Resource Shortages

Successes• Globally there is action toward scaling

up nursing and midwifery education• Increased recognition of the need for

sound long-term human resource strategies including addressing practice environments and retention

• Recognition of the need for quality data to inform these HHR strategies

Economic DownturnSuccesses• Increased interest in the

introduction and regulation of advanced practice nurses as cost-effective ways to deliver care

• Re-looking at models of care -could lead to innovation and improvements to service delivery Potential for dynamic changes in roles and skill mix

Increased focus on regulation and patient safety

Challenges• Increased government oversight

and involvement in regulation • Increased requirement for multiple

levels of reporting• Highlighting there is little or no

research-based evidence on the best regulatory models

Increased focus on regulation and patient safety

Successes• Greater public understanding and

support of regulation• An increased interest in developing

regulatory frameworks in regions where they have not existed or were minimal

• System wide focus on patient safety-recognition that it is multi-dimensional

• Focus on continuing competence and continuous professional development

• Regulation and Education Networks and online discussion forums

• Regulators and Credentialing Forum

• Working with partners to strengthen country and regional systems

• Publications

ICN Regulatory Supports

PUBLICATIONS

• Monographs (Education Trends and Issues, Nurse Prescribing, Reducing the education/practice gap, Regulation 2020)

• Competencies (Across the care continuum; Advanced practice, Disaster nursing )

• Toolkits (Model Act, Scope of Practice, GATs and MRAs)

Enhancing regulatory and standard setting structures

• Find champions and leaders• Get stakeholder involvement • Get the buy-in of government• Support each other through the

process (e.g. regional groupings, working groups, international partnerships)

• Make use of existing resources

Conclusion

• Nurses and midwives must be leaders and collaborators in monitoring and setting standards for education and regulation - to influence positive change, to promote quality care and to improve health for all.