Scope of Practice

When we talk about what different health professionals do and the care they provide, we often talk about their scope of practice. What does that really mean?  

 Scope of practice is the range of health-care tasks, decisions or activities that a qualified, licensed health-care professional is deemed competent to perform, and permitted by their professional colleges to undertake. 

Professional colleges regulate the scope of practice for each profession based on their education and experiences. A scope of practice is a general boundary and does not necessarily mean that an individual provider has the knowledge, skills, or experience to safely perform all activities that are allowed. For example, the scope of practice for an experienced health-care provider and a new graduate may be different. The scope of practice can also vary based on where the health professional is practicing.  

Health professionals have to make sure that an activity or procedure is within their scope of practice. They can do that by asking themselves the following three questions: 

1. Is the procedure or activity within my legislated scope? 
2. Is the procedure or activity supported by my employer and practice setting? 
3. Do I have the knowledge, skills, and judgement to perform the procedure or activity? 

They can only perform the procedure or activity if they can answer ‘yes’ to all three questions.  

Knowledge and skills change as health practitioners gain more work experience in different settings. Health-care providers have to stay up to date in their knowledge and skills through annual professional development. 

Health-care professionals must understand their own scope of practice and the scopes of practice of other providers they work with. This is particularly important if they hand over care activities of patients to another health-care provider. Scope of practice is an important regulation to keep patients and practitioners safe.  

The College of Licensed Practical Nurses (LPNs) of Alberta has developed a tool to help LPNs decide if an activity or procedure is within their scope of practice. While targeted to LPNs, the questions may also help other health-care providers to make safe practice decisions. 

What a health-care provider does in their daily work with patients and their families not only depends on their professional regulation but also on the environment they work in. It is no secret that the scope of practice for rural health-care providers is much broader than the scope of an urban practitioner. 

There are several interesting Canadian studies that looked at the range of activities family physicians/general practitioners perform in rural and urban areas. One study used data from a large physician survey with almost 3000 responses. The study found that most rural family physicians engage in significantly more clinical activities than urban physicians. The breadth of practice, or the number of activities performed, increased with distance to the nearest large full-service hospital and with smaller sized communities. An Ontario study found very similar results.

 …geography is the predominant predictor of scope of practice and plays a greater role in practice breadth than physicians’ sex, age, or type of medical practice. – p.1549

An Alberta study compared the scope of practice of family medicine graduates who completed either an urban or a rural training program. The rural graduates lived and trained in regional settings and gained much of their clinical experiences in rural and remote communities. They found that rural program graduates had a broader scope of practice than the urban graduates. This was evident for the areas of obstetrics and deliveries, palliative care, in-hospital clinical procedures, emergency care, home visits, long-term care, and caring for rural and Aboriginal populations. It was interesting to note that graduates who completed the urban program but ended up in rural practice had a similarly broad range of scope than those trained in the rural program.  

All these studies confirm that practice location shapes the practice experience and daily work. In the absence of large hospitals, specialist services, and other medical support systems, rural health-care providers must broaden their skills to meet the health care needs of the community.  

This is true for all rural health-care providers, not just family physicians. Several sources highlight that nurses, social workers, pharmacists and others working in rural areas need a broad range of knowledge at their fingertips to care for rural residents of all ages:

• Nursing practice in rural and remote Canada
• Rural and Remote Registered Nurses’ Perception of Working Beyond Their Legislated Scope of Practice

Many health-care providers love the diversity that rural practice offers and it is the main reason for choosing to work in rural areas. After all, they trained extensively and want to maintain and expand their skills. This means that diversity of practice is something important to highlight in workforce attraction strategies. 

At the same time, the wide scope of rural practice can be overwhelming for new graduates and could prompt them to leave. A rural health-care provider we spoke to captured this.

 It is not necessarily hard to recruit, but harder to retain nurses; new grads are often overwhelmed by the breadth of the scope. They have to become good at many things vs. being an expert in certain areas. Nurses from urban sites are used to supports from other disciplines, such as respiratory therapists. They don’t find that here. They are responsible for so much more – how do we help them through this transition experience? – Nurse, RhPAP 2018, ‘Building on Success’ project

The broader scope of rural practice requires targeted continuing professional development programming and customized practice supports. RhPAP’s programs aim to support the continuing professional development and the attraction and retention of rural practitioners.  

The health workforce in Alberta is diverse, made up of many different professional groups. Sometimes they have similar roles but each profession also has unique knowledge and skills. Physicians work with other health providers to address the complex health needs of rural patients. For example, nurse practitioners are a growing workforce in Alberta and they can offer a wide range of primary health care services. Others, like social workers or physiotherapists, can offer therapy that is more specific, for example after an injury or surgery, or for mental health support. Their services are an important complement to physician care.

RhPAP has developed resources about different rural health care providers and their roles:

• Advanced Care Paramedic
• Combined Laboratory -X-Ray Technologist
• Dental Hygenist
• Diagnostic Sonographer
• Dietitian
• Health Care Aide
• Licensed Practical Nurse
• Medical Laboratory Technologist
• Midwife
• Nurse Practitioner
• Occupational Therapist
• Pharmacist
• Physician Assistant
• Physiotherapist
• Registered Nurse
• Registered Psychiatric Nurse
• Respiratory Therapist
• Social Worker
• Speech Language Pathologist

Nurse Practitioners (NPs) are a growing workforce in Canada and Alberta. As of 2019, 571 NPs worked in Alberta, an increase of 7.9% from the year before. However, only 6.4% of NPs work in rural settings.

In September 2019, the Alberta Government committed funding to boost the number of NPs working in primary care in rural and underserved areas. Alberta Health Services has developed a strategic plan to help integrate NPs into the workforce and support their practice.

NPs have a broad skillset and their scope of practice allows them to deliver health care to a wide range of patients, especially in the primary care setting. NPs are typically in salaried positions (many of them in Alberta Health Services) and can’t bill Alberta Health directly for their services as physicians do.

Despite the overlap in scope of practice between physicians and NPs, their respective knowledge can be quite distinct based on the focus of their education. NPs are trained in the nursing model that looks holistically at all dimensions of the individual (physical, emotional, mental, and spiritual), including the effects of illness on the lives of the patients and their families. The focus is on prevention, wellness, and enabling patients to self-manage their health. NPs emphasize the social determinants of health within a primary care context. Physicians are trained in the medical model, which in general emphasizes the physical and biological aspects of specific diseases and conditions, and the clinical procedures or strategies to address that defect or dysfunction.

NPs and physicians are both important primary care providers that often work alongside each other and with other health professionals to care for their communities. As independent practitioners, NPs can fill important gaps in health-care services in rural areas.

Health Care Aides (HCAs) have an important role in caring for older Canadians living in long term care facilities or in their homes. Compared to other health professions, HCA are understudied and they are often considered undervalued and invisible.

There are 6800 Health Care Aides employed by Alberta Health Services and many more work in private care facilities and home care services across the province. Health Care Aides care for patients who are ill, elderly or disabled. They assist patients with activities such as bathing, grooming, dressing, and toileting. They may help with feeding or exercise and, in some settings, help patients take their medications.

HCA have an important role in building relationships with the elderly and offering emotional support. This is particularly important for residents without family close by. HCAs typically work under the direction of a registered nurse or a licensed practical nurse and are important members of the interprofessional team.

Until recently, there was no standardized education curriculum for HCAs in Alberta, and they were not regulated. As a result, the training and qualifications of HCA varied greatly, which led to different ways HCAs were used and the roles they were allowed to perform.

The Government of Alberta initiated a comprehensive curriculum review and implemented a provincial curriculum in 2019. There are currently 30 institutions in Alberta that are licensed to teach the Government of Alberta Health Care Aide Provincial Curriculum (2019). The 1-year certificate program includes theory, lab, and work-integrated learning experiences. At the end of the certificate program, HCAs are required to complete the Government of Alberta Provincial Exam.

Non-certified HCAs that are employed and would like to get certification can attend the Employed Student Tutored Education Program (eSTEP) offered by Northern Lakes College. This is an online self-study program that provides tutorial support and resources that students require to gain certification as a HCA in Alberta. The program offers flexibility, so students can continue to work.  At the end of their one-year training, students are also required to complete the Government of Alberta Provincial Exam.

The standardized assessment helps to determine that HCA students have the competencies to safely deliver care. HCAs working for a publicly funded employer also must enroll in the Alberta HCA Directory and provide their official transcript. This will ensure that HCAs have attained the required education.

Most recently, Alberta has moved to regulate HCAs as part of Bill 46, the Health Statutes Amendment Act, which passed into law early 2021. The College of Licensed Practical Nurses of Alberta will be the regulator. HCA will be regulated as a separate profession within the college.

The standardized curriculum and regulatory process are seen as positive developments to protect Albertans by requiring HCAs to adhere to the same regulatory standards as other health professionals in Alberta.

The demand for health care aides continues to grow. Strengthened as a profession through standard competency requirements and regulation, they have an important and necessary role in delivering health care in Alberta. This makes the HCA profession a great career choice.

Pregnancy is an important time with a large focus on health care. Several health providers can support Albertans during pregnancy, labour, delivery, and post-pregnancy care. Often different providers care for pregnant women and their families at different times during pregnancy, labour and delivery, and the postpartum period.

Below is a short summary of the most common providers that offer maternity care and their scope of practice in Alberta: 

General or family practitioners (GPs) – are medical doctors that provide primary health care to patients throughout the lifespan. They can confirm a pregnancy and answer general questions. Some GPs provide pre-natal care and deliver babies. They can also assess a pregnancy to determine if specialist care is needed and then make a referral. GPs most often support hospital deliveries, although they can facilitate home births.  

General family practitioners with enhanced surgical skills – are medical doctors that provide primary health care. They have additional specialized training that allows them to provide cesarean sections (c-sections) and other obstetrical procedures in their scope of practice.  

Obstetricians and Gynecologists (OB/GYNs) – are medical doctors that specialize in the treatment of care related to pregnancy, birth and female reproductive health. An OB/GYN can manage all aspects of pregnancy, delivery, and post-partum care. They can also perform surgeries, including cesarean sections (c-sections) if needed. 

Registered Midwives – are primary health-care providers for low-risk pregnancies. A Midwife cares for women and their babies during pregnancy, labour, birth, and the postpartum period. This includes physical examinations, screening and diagnostic tests, and delivery of the baby.  Midwives can support deliveries at home, in a birthing centre, or at the hospital.

Nurse Practitioners (NPs) – are primary health-care providers for low-risk pregnancies. They provide physical examinations, screening and diagnostic tests, and postpartum care. NPs will collaborate with a physician or midwife for the actual delivery of the baby. NPs provide care through community family care clinics and primary care networks.  

Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) provide care for women and babies during hospital births. Public Health Nurses also provide postpartum care during the first six weeks after the baby is born.

Doulas – provide emotional support and comfort during pregnancy, labour, and delivery. They are not regulated health providers and the cost for their services are not covered by Alberta Health Services. Doulas provide support during home births or at birthing centres and hospitals.

The High River Maternity is a rural Alberta example of collaborative care, in which doctors, midwives and nurses jointly care for women throughout their pregnancies. The maternity unit was recently renovated with funding raised by the community. Learn more about this collaborative maternity service by watching the video below. 

In 2019, there were almost 140 midwives in Alberta. However, most of them are based in Calgary and Edmonton and serve surrounding communities. Less than 20 midwives practice in rural areas of the Province.

One of the priorities of the Alberta Association of Midwives, Alberta Health Services, and Alberta Health is to establish midwifery practices in rural areas and to improve access for all Albertans. Two strategies are helping to achieve this:

1. Increasing the number of funded midwifery births: Alberta Health has increased the number of funded births that midwives can provide at not cost to patients. In 2019,  an agreement was reached to implement a program to help midwives service Indigenous and underserved populations, and women in rural and remote communities.
2. Expanding midwives scope of practice: Midwives who complete additional training and are authorized by the College of Midwives of Alberta can now prescribe, dispense and administer a broader range of prescription drugs, contraceptives and, in a hospital, narcotics. They can also prescribe and administer vaccines, insert intrauterine contraceptive devices, provide prescription drugs to induce labour, and use ultrasounds to determine fetal position. 

These changes will allow more midwives to practice, perform more tasks during labour, and provide greater postnatal care. These expanded services particularly benefit women in rural communities. Already rural communities are seeing an increase in midwives. For example in Grande Prairie, Ft. McMurray, and Lac La Biche.

 This means a new era in professional status for Alberta’s registered midwives. This change will allow midwives to make fuller use of their knowledge and skills in the provision of high-quality, cost-effective maternity care for Alberta’s child-bearing families, and increase access to primary care in rural, remote and underserved communities. –Cassondra Evans, president, College of Midwives of Alberta 

Click here to listen to the Alberta Midwives: Our Stories podcast episode Rural Midwifery is Catching!   

Many health professions have seen their scope of practice expand over the past years. One reason for this is that health care is continually changing. Advances in technologies, best practices, and medications require health providers to have additional competencies that were not part of their original education.

For example, pharmacists in Alberta are now able to:

• renew, adjust, and initiate prescriptions;
• order and interpret laboratory tests; and
• administer injections and vaccines.

As a result of this expanded scope of practice, pharmacists can now offer more services to their communities (such as vaccinations, smoking cessation therapies) and take on a bigger role in patient care through medication reviews and management of certain chronic conditions.

Studies show that pharmacists giving vaccinations has increased vaccination rates.

When pharmacists are involved in caring for patients with chronic conditions, patients may see better outcomes. Patients with chronic conditions often take multiple medications. Pharmacists, with their in-depth knowledge of drugs, can help keep minimize side effects and keep patients safe.

Pharmacists can also help physicians keep abreast of new drug developments. When physicians and pharmacists jointly care for patients, it is really important that they have good communication and inform each other of any changes in drug regime or patient health.

In rural areas with physician shortages, having pharmacists take on an expanded role in patient care is particularly helpful. It allows patients to quickly access a health-care provider in their community to refill their prescription or discuss drug side effects.

Apart from the benefits to patients, there is also an economic benefit of expanded pharmacy services. A study by the Conference Board of Canada projects that community pharmacy services can create substantial savings in health care-costs.

Browse the videos below to get a sense of “a day in the life of” different health providers.

Nurse Practitioner

Registered Nurse

Licensed Nurse Practitioner

Pharmacist

Advanced Care Paramedic

Respiratory Therapist

Midwife

Physician Assistant