CRNBC Policy Program Review 2016€¦ · Are we too vested in our own advice? Phase 6: Dissemination Addressing questions such as: Have we considered how we might disseminate the

Review of CRNBC Policy Processes and Products

Prepared for: Christine Penney, CRNBC

Prepared by: Lillian Bayne, Lillian Bayne and Associates

September 2016

1

Review of CRNBC Policy

Processes and Products



September 2016




September 2016

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Review of the CRNBC Policy Processes and Products

1. Background:

Nursing has been a regulated health profession in the province of British Columbia since 1918,

regulated by the Nurses (Registered) Act until 2005 when it was brought under regulations - Nurses

(Registered) and Nurse Practitioners Regulation - pursuant to the province’s Health Professions Act.

Since that time, the College has been shifting from its previous role as both a professional

association, advancing the profession, and as a professional regulatory body, protecting the public, to

a role focused solely on its legal obligation to protect the public through the regulation of registered

nurses and nurse practitioners. The College meets its legal obligation in three ways:

by setting requirements for initial registration and establishing minimum standards by which

registrants must practice;

by supporting registrants to meet these standards; and

by acting if these standards are not met.

Over the past several years, CRNBC has been systematically reviewing its programs for alignment

with its public protection mandate and its underpinning philosophy and strategic plan as well as with

contemporary and “best” practice in professional regulation.

The Policy, Practice and Quality Assurance (PPQA) department focuses on the development of

policy to guide professional nursing practice, and the dissemination of policy to registered nurses

and nurse practitioners to inform, direct and guide their professional practice. The main policy

products include “standards”, “limits and conditions” and regulatory mechanisms such as “named

agency” and “additional education”.

This review explores the current literature, stakeholder experiences and views, and emerging trends

affecting the regulatory policy process and the key policy products that CRNBC employs.

1.1 Approach

This review involved a search of the literature on policy processes related to professional regulation

and on evidence of the effectiveness of the various policy “products” employed to regulate

professional practice.

The review also involved consultation with experts through key informant interviews and focus

groups. Fifty-eight (58) key informants - including program staff, representatives of other regulatory

bodies, representatives of selected nursing associations, nursing policy- and decision-makers/leaders,

and academic researchers - from within BC, across the country, and based in the US and UK were

consulted through one-hour telephone interviews and 1½ to 2 hour face-to-face and teleconferenced

focus groups. A common interview guide was used to structure both methods of consultation. Please

see Appendix A for a list of those consulted – referred to throughout this document as “respondents”

- and Appendix B for a copy of the interview guide.




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1.2 Purpose

This report summarizes the findings from the literature review and expert consultation and presents

some considerations for the future.

2. Findings

It has become clear to many policy-makers that healthcare is a system replete with so-called “wicked

problems” - problems that are difficult to define, usually have no clear solution, often result in

unforeseen consequences when superficial attempts to address them are made, and are subject to

chronic policy failure as a result. Wicked problems are often unstable, have many interdependencies

and are commonly multi-causal. They are socially complex and require changes in behaviour. They

seldom fit within the responsibility of any one organisation (Australian Public Service Commission

2007).

Given the challenges presented by wicked problems, it is not surprising that healthcare is a

“‘pluralistic regulatory landscape’ where numerous organisations with overlapping responsibilities

attempt to implement rules and encourage certain behaviour” (Quick, 2011, p4).

While there remains little solid evidence of the precise impact of regulatory instruments or

mechanisms on human behaviour, there is a growing recognition of the importance of “human

factors” and their interplay with contextual variables such as leadership, professional identity,

worksite culture, physical space, and intrinsic and extrinsic rewards, and of the need for boundary-

spanning across organizations involved in “governing the gap” between “abstract rules and situated

practice” (Huising and Silbey, 2011) when regulating “people, places and products” (The Health

Foundation, 2013).

2.1 Policy Processes

CRNBC’s 2015 “Framework for Policy Development” (CRNBC, 2015) identifies key phases for

regulatory policy development and presents a good framework for describing and analyzing current

policy development practice. The seven phases of the process and the kinds of questions that inform

work at each phase are presented in Exhibit 1 below.




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Exhibit 1: Phases of CRNBC Regulatory Policy Development

Phase 1: Inputs/Identifying Issues

Addressing questions such as: Has the legislation changed? Has the health care environment changed? Is practice

evolving? Does the College’s mandate support further or continued work on the issue? Is it in (or still in) the public

interest to consider the issue?

Phase 2: Explore and Define the Issue

Addressing questions such as: Do we understand the history and context of the issue? Do we understand current

regulatory practices and legal requirements around the issue? Do we understand the perspectives of different

stakeholders? Have we defined the issue clearly enough to give us focus when developing options to deal with it?

Phase 3: Consultation

Addressing questions such as: Have we identified key stakeholders/who should be consulted? What consultation

methods should be used? At what stage(s) should the consultation(s) occur?

Phase 4: Develop Options

Addressing questions such as: Have we considered the broadest possible range of options? Have we identified the

preferred, most relevant or most suitable options based on factors such as: consultation with stakeholders, degree of

risk, experience/solutions used elsewhere (e.g. other jurisdictions), advice of legal counsel, cost/benefit/financial

implications? Do we have the resources/authority to implement this option? Have we considered the possible

adverse or unintended consequences that might arise? Have we considered how stakeholders will respond?

Phase 5: Decision Making

Addressing questions such as: Have we developed information on policy options considered? Have we developed

detailed background material to support the decision making process? Have the possible pitfalls with choosing the

various options been identified? Have we considered the perspective of the decision-makers in formulating the

options? Are we too vested in our own advice?

Phase 6: Dissemination

Addressing questions such as: Have we considered how we might disseminate the policy option decided upon?

Have we developed a dissemination strategy including communication, publicity, education and evaluation? Is our

dissemination strategy sufficiently robust to prompt behavioral change?

Phase 7: Policy Review

Addressing questions such as: Are there any significant concerns that might warrant revision of the policy sooner

than the review schedule indicates? Have we identified improvements to the policy that might be proposed?

Source: CRNBC. 2015

Many respondents have had experience with processes designed to identify priority issues and to

develop solutions. While there is a growing recognition of the need to work collaboratively across

the healthcare system, efforts to systematically and comprehensively engage other players to identify

common and persistent issues and to design solutions that allow for the integration of respective

mandates and domains of influence remain extremely limited.

Many different approaches to issue identification were suggested by key informants including

environmental scanning; consultation with internal leadership teams and Board members; and

mining of internal databases. Most often, however, issues requiring attention tended to be identified

or imposed by others such as government (strategic agenda priorities or responses to media or public

pressure) or by legislative or legal changes. The Ontario College of Nurses is developing a risk-




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based approach to issue identification that applies a “risk lens” to determine whether a given issue

presents a risk to the public interest. The definition of “risk” in this case is broader than the risk of

harm by a registrant to a patient. It includes a consideration of whether there is a risk to safe,

effective and client-centred care, but also whether there is a risk to the internal organization or to the

health system. The “risk lens” is used to assess the nature of the risk, to determine whether it is

shared among others than just registrants of the College; whether it is unique to a given setting; and

whether the regulator is the body required to address it.

Approaches to developing a robust understanding of the issue noted by respondents include

consultation with affected parties, consultation with key informants or subject matter experts,

conducting literature reviews, and in some cases commissioning full evidence syntheses.

Consultation with those affected by the issue is considered by most to be essential in developing a

full understanding of the history and context of any given issue as well as in identifying feasible and

acceptable solutions. However, few regulators appear to use robust, comprehensive, and consistent

processes for engaging all key players in developing a full understanding of an issue. Following a

review of the literature and of best practices in addressing “wicked problems”, the Australian Public

Service Commission concluded that “…creating a shared understanding of the wicked problem

among the range of organisations that can contribute to a full understanding and comprehensive

response to the issue” is key to successful resolution(Australian Public Service Commission. 2007.

p2). They state emphatically that “[u]nintended consequences tend to occur even more frequently if

the problem has been artificially tamed, that is, it has been too narrowly addressed and the multiple

causes and interconnections not fully explored prior to measures being introduced.” (Australian

Public Service Commission. 2007. p12).

Most regulatory and other policy-making bodies engage stakeholders – in some cases simply

registrants, in other cases other interested or affected parties, including the public – in opinion

surveying. Most surveyors offer respondents the option of continuing to be or becoming more

involved in sharing their views or advice through further surveying, service on panels, or

engagement in advisory or governance structures. For some regulators, routine engagement with

registrants through standing structures such as widely representative advisory bodies (representative

of geographic/regional, age and career stage, speciality, setting type differences, for example)

provide essential sources of information on what issues are on the horizon, what solutions might be

considered, and how solutions may be implemented. Although many regulators see public

engagement as critical, few have developed strategies for doing this (please see discussion in section

2.3 below for more on public engagement).

Once issue solution options have been fully considered and decisions made on what course of action

to take, most regulators rely on their websites and routine communications through newsletters to

registrants to inform people. While some basic metrics are often kept on numbers of visits, and time

spent on each website “page”, there is little solid evidence on the effectiveness of these methods of

communication in reaching those who need to know about and understand the implications of

regulatory decisions or changes.




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There is a paucity of literature or practice in evaluation of policy “products” (Quick, 2011). Most

regulators review their products on a routine basis, generally for currency not impact or

effectiveness, according to a schedule for review and revision.

The policy process developed by McMaster University’s “Health Forum” employs a comprehensive

and systematic process for addressing health system issues that my include rapid syntheses of the

literature, the production of evidence and issue briefs, the engagement of citizen panels, stakeholder

dialogues, and video and audio podcasts.

2.1.1 CRNBC Regulatory Policy Processes

While CRNBC has developed a draft “Framework for Policy Development”, it is not well known

either outside or within the organization, even among those one would expect to be using the

framework to inform their work. Some external respondents expressed a deep appreciation for the

thoughtful and careful processes engaged by CRNBC, which were seen, for the most part to be

transparent and systematic (there is a sense among some that the process for merging the nursing

colleges has been “rushed” at some stages).

While CRNBC respondents were able to reference a process that had been employed in one case or

another, there is not a sense among them that the same measured and methodical process is

employed for all issues. There is a sense that the policy process tends to be isolated from other

CRNBC processes with which it should be intimately connected for mutual gain (for example,

registration and renewal and complaints and concerns). The perception of an unnecessarily “silo-ed”

organization appears to be a dominant one.

As with many respondents, there was acknowledgement within CRNBC that most policy “priority

areas” were topics generated by external forces such as government policy or legislation, though the

leadership team and Board were also seen as key sources of issue identification. Several CRNBC

respondents felt more could be done to mine internal databases and sources to identify emerging

issues or priorities for action.

Once identified, CRNBC’s exploration of issues is typically undertaken by conducting literature

reviews, jurisdictional scans and consulting with key informants and affected parties. As is the case

with most regulators surveyed, this consultation is generally project- or issue-focused rather than

being open-ended with the intention of revealing common or emerging issues. CRNBC respondents

noted that the development of options routinely engages external stakeholders, but seldom beyond

the “usual suspects” of Ministry representatives, Chief Nursing Officers, and health authority “HPA

Leads”. There was a sense that, if and when registrants are consulted, this tends to be limited to an

opportunistic sample of those who have expressed a keen interest or who are already involved in

CRNBC activities, rather than seeking to engage a representative sample of registrants and settings.




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Takeaways and Considerations for CRNBC:

CRNBC is viewed as forward-looking, critically reflective, and engaging by many of those

who are routinely consulted for advice or information on best practices.

CRNBC may wish to make more concerted use of the data it collects from registrant

inquiries and from the complaints process as critical sources of information on emerging

issues.

Greater effort to engage a wider range of registrants, including more methodical approaches

to creating representative samples of respondents to surveys/participants in focus groups,

could reap benefits in terms of broader understanding and greater appreciation of the role of

the regulator among registrants and is consistent with the relational philosophy of the

College.

Opportunities to engage through the Association(s) where appropriately aligned with

Association role and resources may be cost effective.

2.2 Regulatory Policy Products

There are many ways to influence or even to compel human behaviour from practices or instruments

that are more overt – written rules, traffic signals, stipulations in contracts for example – to those

that are more subtle – such as product placement on grocery store shelves or observed peer leader

behaviour. Even within these, the effect of the instruments may be quite different depending on

context and the predisposition of the individual(s) involved: think of a barrier at a parkade that does

not allow you to exit until you have paid, versus a red light in a heavy traffic area, versus a sign

posting the speed limit on a straight open road (Thaler and Sustein, 2009). Healy and Braithwaite

(2006) present a broad definition of regulation as mechanisms that ‘[steer] the flow of events” and

argue for “‘responsive regulation’ – the use by regulators of mechanisms that are responsive to the

context, conduct and culture of those being regulated” (pS56). They offer a “regulatory pyramid”

that provides examples of mechanisms that fall within their broad conception of regulation.




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Exhibit 2: Regulatory Pyramid

Regulations are a class of practices or instruments designed to shape or direct behaviour or to

“conduct conduct”. Julia Black argues for a “decentred understanding of regulation [that]

emphasises both causal complexity and the complexity of interactions between actors in society (or

systems)” (Black, 2002, p5) or, in the words of Susan Silbey, it is a conception that engages the

“sociological citizen, a pragmatic actor who sees her work and herself as a link in a complex web of

unfolding transactions and processes” (Silbey, 2011, p3). However, Black offers a more delimited

conception of regulation as a “sustained and focused attempt to alter the behaviour of others

according to defined standards or purposes with the intention of producing a broadly identified

outcome.” (Black, 2002, p25). While Black argues that regulation may be “decentred” - that it need

not be of a government “command and control” nature and that it is mediated by contextual variables




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- her definition is helpful in distinguishing regulation from “any 'thing' that structures or constrains

the behaviour of individuals, organisations, or systems” (Black, 2002, p25, my emphasis).

The concept of “right-touch” in regulation includes the principle that “regulators should only

intervene when necessary” (Professional Standards Authority, 2015, p4). The UK’s Professional

Standards Authority presents a decision algorithm to guide deliberations on whether regulation is the

most appropriate mechanism for addressing any given concern.

Exhibit 3: The Right-touch Regulation Decision Tree

Professional Standards Authority, 2015, p8




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2.2.1 CRNBC Policy Products

CRNBC employs a variety of policy “products” or mechanisms to regulate registrants, chief among

these being “professional, scope and practice standards”; “limits and conditions”; “named agency”;

“certified practice”; and “additional education”. While some of these terms are identified and

defined on the CRNBC website and in accompanying documents, some are not.

Standards, Limits and Conditions

CRNBC has the authority under the Health Professions Act to “establish, monitor and enforce

standards, limits and conditions for registered nurses’ practice”. While they seem straightforward,

the terms “standards, limits and conditions” are not universally understood by all health professions.

For physicians, standards are baselines for behaviour and conduct that apply to all registrants of the

profession. Limits to physicians’ scopes are defined according the terms of the defined licences they

hold (for example, Full – general/family, Full-specialty, Emergency, etc.), while conditions are

often, though not always, “reactive to the complaints process” and relate to the practice of individual

physicians (for example, restrictions on the number of patients the physician may see in any given

day or the requirement to see patients only in the presence of a chaperone).

CRNBC defines standards, limits and conditions – or SLCs - as follows:

Standard: A desired and achievable level of performance against which actual performance

can be compared. It provides a benchmark below which performance is unacceptable.

Limit: Specifies what registered nurses are not permitted to do.

Condition: Sets out the circumstances under which registered nurses may carry out an

activity. Source:

https://www.crnbc.ca/Standards/Lists/StandardResources/433ScopeforRegisteredNurses.pdf#search=limits%20and%

20conditions accessed June 2016

Standards of Practice

For CRNBC, standards provide “high level” guidance to professionals either generally (as with

“professional standards”), about scopes of practice and the pertinent standards, limits and conditions

(as with the scope of practice standards) or with a focus to specific areas of practice (as with

“practice standards”). The practice standards are a subset of standards that provide additional detail

on one or more of the professional or scope of practice standards. CRNBC identifies 4 “professional

standards”, 2 “scope of practice standards” and 17 “practice standards”.

https://www.crnbc.ca/Standards/Lists/StandardResources/433ScopeforRegisteredNurses.pdf#search=limits%20and%20conditions





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Professional Standards:

The Professional Standards, which are one set of standards under the umbrella of CRNBC

Standards of Practice, are statements about levels of performance that nurses are required to

achieve in their practice. The Professional Standards:

Reflect the values of the nursing profession

Clarify what the profession expects of nurses

Represent the criteria against which nurses’ practice in British Columbia is measured by

clients, employers, colleagues, themselves and others

Source: https://www.crnbc.ca/Standards/ProfessionalStandards/Pages/Introduction.aspx accessed June 2016

Scope of Practice Standards:

The scope of practice for registered nurses and nurse practitioners in BC is set out in the Nurses

(Registered) and Nurse Practitioners Regulation under the Health Professions Act. CRNBC sets

the standards, limits and conditions by which registered nurses and nurse practitioners may carry

out nursing activities that are within the nurses’ scopes of practice. The Scope of Practice for

Registered Nurses: Standards, Limits and Conditions and The Scope of Practice Standards for

Nurse Practitioners: Standards, Limits and Conditions outline those standards, limits and

conditions.

Source: https://www.crnbc.ca/Standards/NPScopePractice/Pages/Default.aspx Accessed June 2016

https://www.crnbc.ca/Standards/RNScopePractice/Pages/Default.aspx Accessed June 2016

Practice Standards:

Practice Standards set out requirements related to specific aspects of nurses' practice. They link

with other standards, policies and bylaws of the College of Registered Nurses of British

Columbia and all legislation relevant to nursing practice. The primary purpose of the Practice

Standards is to guide and direct nurses' practice. They set out levels of performance that CRNBC

registrants are required to achieve in their practices.

Source: https://www.crnbc.ca/Standards/PracticeStandards/Pages/titles.aspx accessed June 2016

https://www.crnbc.ca/Standards/ProfessionalStandards/Pages/Introduction.aspx

https://www.crnbc.ca/Standards/NPScopePractice/Pages/Default.aspx%20Accessed%20June%202016

https://www.crnbc.ca/Standards/RNScopePractice/Pages/Default.aspx

https://www.crnbc.ca/Standards/PracticeStandards/Pages/titles.aspx




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CRNBC Practice Standards

1. Appropriate Use of Titles

2. Boundaries in the Nurse-Client Relationship

3. Communicable Diseases: Preventing Nurse-to-Client Transmission

4. Conflict of Interest

5. Consent

6. Delegating Tasks to Unregulated Care Providers

7. Dispensing Medications

8. Documentation

9. Duty to Provide Care

10. Duty to Report

11. Employed Student Registrants

12. Medication Administration

13. Medication Inventory Management

14. Privacy and Confidentiality

15. Providing Clinical Directions

16. Regulatory Supervision of Nursing Student Activities

17. Telehealth

Source: https://www.crnbc.ca/Standards/PracticeStandards/Pages/Default.aspx accessed June 2016

Standards are meant to keep pace with practice, reflecting emerging technologies and areas of risk.

As stated by CRNBC, “whenever possible… standards (rather than limits and conditions) [are used]

to provide direction for practice”. As guidelines for professional practice, standards call on the

exercise of professional judgement, while limits and conditions, being restrictive and specific in their

nature, are less able to reflect the realities of ever-changing contemporary practice.

Regulatory Mechanisms and Registrant Competence

CRNBC regulates entry to practice competencies to ensure competent nurses enter the system.

However, health professions regulators generally do not regulate speciality practice as this has

traditionally been in the employer domain. During the transition to the Health Professions Act, and

arguably while the service delivery system was in transition to regional health authorities, several

mechanisms were created and implemented to address the need for standardization across the

province. These mechanisms, which develop and distribute best practice evidence around various

clinical conditions to nurses at the bedside, pull CRNBC regulation somewhat into health systems

regulation. By contrast, the medical services program at the Ministry of Health provides the

provincial infrastructure for this type of service for physicians. As the province’s strategic directions

shift to inter-professional/interdisciplinary teams and patient-focused care, the question arises as to

whether the provincial infrastructure is better placed to provide this service for all health professions

https://www.crnbc.ca/Standards/PracticeStandards/Pages/Default.aspx%20accessed%20June%202016




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to ensure consistent, patient-focused clinical guidelines for the interdisciplinary team and

interprofessional practice.

CRNBC does have other mechanisms for restricting practice, including requirements for

certification in certain areas, requirements for registrants to meet the competencies identified and the

clinical practice guidelines (also known as decision support tools) outlined by a named agency and

requirements for registrants to complete additional education before being qualified to provide

certain services.

Certified Practice

CRNBC registers RNs in four certified practice areas, each with a designated BC institution

approved to provide the necessary training in the area:

RN First Call

Remote Nursing (RNs certified in Remote Nursing must also be certified in Reproductive

Health Certified Practice: Sexually Transmitted Infections and Contraceptive Management)

Sexually Transmitted Infections - Reproductive Health

Contraceptive Management - Reproductive Health

In order to obtain a CRNBC-Certified Practice designation an RN must either (a) complete CRNBC-

approved coursework and/or (b) have documented practice experience, validated by successful

completion of an approved course “exit evaluation”. Certified nurses may independently carry out

designated restricted activities following CRNBC-approved Decision Support Tools (DSTs).

Additional Education

The requirement for additional education is less specific. Although it is referred to as a condition for

performing certain activities, such as cardiac stress testing or aiding in the provision of medical

assistance in dying, and is defined as “structured education (e.g. workshop, course, program of

study) designed so that registered nurses can attain the competencies required to carry out a specific

activity as part of registered nursing practice” there are no specifications for what “workshops,

courses or programs of study” are acceptable or signify acquisition of the needed knowledge, skills,

and attitudes or competencies required to “carry out a specific activity”. This may create confusion

for the nurse trying to determine the meaning of a limit or condition. For example, CRNBC limits

and conditions in cardiac stress testing state that:

Registered nurses may only carry out cardiac stress testing under a physician’s direction and

only following successful completion of additional education.

(source:

https://www.crnbc.ca/Standards/Lists/StandardResources/433ScopeforRegisteredNurses.pdf#search=limits%20

and%20conditions accessed June 2016)

Does site-specific training by the physician in question constitute sufficient and acceptable

“additional education”? Is this “additional education” now transferrable to another setting? Who is






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responsible for ensuring that the required “additional education” has been acquired or that the

content has been understood?

Where there is specificity in naming acceptable educational settings and the requirement of

successful completion of an “exit evaluation” for the acquisition of certified practice, there is no

such guidance in relation to the ubiquitous requirement for “additional education”. A 2015 document

prepared by CRNBC (December, 2015) indicates that “additional education” offers “low” regulatory

control by the College, compared with a designation of “high” level of control for “certified

practice”.

Named Agency

A similar concern relates to the application of the designation named agency, a term which does not

appear as a product of a CRNBC website search. A CRNBC document developed in 2015 provides

this description:

Leads to provincial consistency using a provincial expert group to develop competencies and

any required decision support tools (DSTs).

The named agency process does not authorize the regulatory body to determine the required

competencies or DSTs. (CRNBC, December 2015, p.1)

The term applies to an “agency” – generally a BC health authority or a specific practice site within a

health authority – that has been designated by CRNBC as the authority in the determination of

competencies and the development of required decision support tools (DSTs) for a given specialty

practice area. Employers then use the approved “limits and conditions” – “expectations” - implied by

the identified competencies and DSTs to assess and support registrants’ abilities to perform the

related tasks.

Where the “agency” in question has a pan-provincial mandate – such as the BC Centre for Disease

Control (part of the Provincial Health Services Authority or PHSA) which is the named agency for

immunizations - the resulting “standards” or clinical protocols may be disseminated across the

province and provide guidance to those operating at multiple different sites and settings. Despite the

expectation that the decision-support tools are intended to provide provincial standardization for

nurses, in locations where they are more site-bounded, such as St Paul’s Hospital’s nursing protocols

related to cardiac care, it is not clear how they are taken up by others across the province.

There is little understanding of the function of “named agency” as a regulatory mechanism. When

asked to define the term, CRNBC staff consulted each have different conceptions. Most nursing

practice leaders in the field are not clear on how the mechanism functions and those who are see it as

significantly time-consuming for the “named agency”. Although it is deemed by CRNBC to have a

“moderate” level of regulatory control, it is not clear how this control is exercised, nor how its

effectiveness is monitored.




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While CRNBC’s regulatory products appear to be routinely reviewed for currency according to a

schedule, there appears to be no robust assessment of the effectiveness of the products against their

objectives. Products do not appear to be subjected to comparison across type to ensure consistency.


Review of the various regulatory mechanisms employed by CRNBC for consistency across

type – asking for example, “are the message and the intent of this standard consistent with

the message and intent of our bylaws?” – would help to reduce any confusion that may result

from “mixed messages”.

Given the confusion related to the use of additional education as a regulatory approach, it

would be valuable for CRNBC to further articulate what determines when a “low” level of

regulatory control, is the appropriate approach versus a “moderate” or “high” level of

regulatory control. This would be an important concept to validate with stakeholders as well.

Greater clarity is required to ensure that some regulatory mechanisms are understood. At

present, there is very limited understanding of the term “named agency”, even within

CRNBC.

The lack of specificity in some CRNBC policy “products” may result in accountability

confusion and even accountability gaps that expose the regulator.

The lack of robust evaluation of products against the intended objectives makes it difficult to

ensure that there is consistency and the most appropriate application of a regulatory product.

2.3 Stakeholder and Public Engagement

The need to involve stakeholders and the public in all phases of policy development, from the

identification of issues through to the evaluation of the impact of policy instruments, is widely

recognized. The value, while not well quantified, is seen to be in relevance, acceptability, and

effectiveness of policy products. A wide variety of mechanisms or modes of engagement may be

used, varying in cost and generating different outputs and outcomes.

A key conclusion of much of the literature about wicked policy problems is that effectively

engaging the full range of stakeholders in the search for solutions is crucial. Engagement is most

important when the active participation and cooperation of citizens is required as part of the

solution. …. Because wicked problems are often imperfectly understood it is important that they

are widely discussed by all relevant stakeholders in order to ensure a full understanding of their

complexity. If a resolution of a wicked issue requires changes in the way people behave, these

changes cannot readily be imposed on people. Behaviours are more conducive to change if

issues are widely understood, discussed and owned by the people whose behaviour is being

targeted for change. (Australian Public Service Commission, 2007, p27)




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2.3.1 Stakeholder Engagement Experiences

As reflected in the experience of the Australian Public Service Commission cited above, the

engagement of stakeholders is necessary to develop a robust understanding of the policy issue, as

well as to enable the design and support the implementation and uptake of an appropriate solution.

The most comprehensive and methodical engagement of stakeholders reported by key informants is

through the McMaster Health Forum:

For concerned citizens and influential thinkers and doers, the McMaster Health Forum strives to be a leading hub for improving health outcomes through collective problem solving. Operating at regional/provincial levels and at national levels, we harness information, convene stakeholders and prepare action-oriented leaders to meet pressing health issues creatively. The Forum acts as an agent of change by empowering stakeholders to set agendas, take well-considered actions and communicate the rationale for actions effectively. Source: McMaster Health Forum. https://www.mcmasterhealthforum.org

Many respondents noted the merit of stakeholder “mapping” to ensure identification of all relevant

stakeholders. The engagement of registrants by regulatory bodies in the co-creation of regulatory

mechanisms was seen as essential to securing full understanding of the need for, intent, and

operation of a given mechanism, and to achieve “buy-in”/compliance and use/uptake. Ensuring that

registrants understand the objectives and content of standards seems critical given the dependence on

registrant self-assessment of competency associated with most of the instruments employed by

CRNBC.

Several respondents noted the need for transparency, consistency and openness in registrant

engagement processes. Engagement of a representative sample of registrants, those at or in different

career stages, geographic realities, and settings or sectors, is essential to ensuring the resultant policy

mechanism is understood, relevant and valid in all cases where it needs to be applied.

For those respondents who strongly favoured a role for the regulator in “helping registrants to do the

right thing” rather than “stopping registrants from doing the wrong thing”, the building of mutually

respectful relationships with registrants is seen as essential.

https://www.mcmasterhealthforum.org/




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2.3.2 CRNBC’s Stakeholder Engagement

CRNBC is lauded by many organizations for its efforts to engage stakeholders and is seen as a keen

and valuable partner on policy issues. Indeed, in its review of CRNBC, the Professional Standards

Authority found there to be “good engagement with clinicians and registrants in the development of

guidance and standards. These groups are engaged by means of interviews, focus groups, surveys

and expert panels.” (Professional Standards Authority, 2016, p17).

While some respondents questioned the degree to which CRNBC sought and engaged the less

obvious stakeholders, several noted that the breadth of CRNBC’s stakeholder engagement appears to

be wider than most regulatory bodies which have neither the reputation/credibility nor the

resources/size to do what CRNBC does.

CRNBC relies heavily on its website and newsletter to communicate with registrants.

Though few if any external respondents knew how CRNBC engages or attempts to engage

registrants, those respondents who were aware expressed the sense that the processes and approaches

used by CRNBC were somewhat formulaic and routinized and generated participation by only a

small, not necessarily representative, subset of registrants or consistently engaged the same set of

participants.

2.3.3 Patient and Public Engagement Experiences

A review of public engagement conducted by the Council for Healthcare Regulatory Excellence

(2011, p1) found that [p]articipation by patients and the public is regarded as an essential aspect of

healthcare regulation. Many regulators have built this into their constitution and governance

structures and have adopted a wide range of practical approaches to allow participation. However,

the Council report as well as the survey of key informants revealed that the engagement of patients

and the public presents significant challenges and few feel confident that they have designed optimal

approaches for this.

All respondents noted the importance of engaging the public in developing public policy. Public

engagement is seen as essential for an agency whose mandate is to protect the public. Exhibit 4

below presents a summary of the types of approaches identified by respondents as ways to engage

patients and the public. It was noted that, if the intent it to reflect public views or perspectives,

engagement approaches need to ensure representativeness; effort must be invested in constructing

samples that reflect the demographics, geography, and culture of the general public.




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Exhibit 4: Approaches to Engaging Patients and the Public

After the use of the organization’s website, the method of public engagement most often employed is

opinion polling via survey to identify important issues, identify public expectations, or to assess the

perceived quality of services/functions delivered. The key to success is rendering the topic on which

engagement is being sought relevant to the public. A major challenge for regulators is that there is

very limited understanding of the role of the regulator among members of the public and it is

difficult to generate sufficient interest to support constructive input via survey. The topic must be

rendered in a manner that captures the public interest and capitalizes on knowledge or views that

they would wish to share.

Some respondents had experience with formalized, ongoing public advisory “panels”: members of

the public who were fully oriented to the role and function of the organization they were working

with or the system (healthcare) they were working in who would provide advice on an as-needed

basis. The construction of such a panel involves a significant investment of time, however, it is seen

to pay dividends in terms of the quality of the advice and input provided.




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Some respondents had experience with one-time “citizen panels”, constructed to address a specific

issue or concern. McMaster University’s Health Forum has extensive experience in this regard.

They advise careful attention to the participant recruitment process to ensure diversity, and underline

the need for solid evidence as an input, and a refined process to contextualize the issue, to ensure

meaningful engagement of participants.

Some respondents strongly encouraged finding opportunities for partnering in public and patient

engagement around issues of concern. This can lead to a more robust conception of the issue or topic

under consideration and a broader impact or relevance for the results. A collaborative approach is

seen as particularly relevant for regulators serving the public interest. The common objective of

protecting the public or ensuring patient safety is a unifying one for many public policy-making

agencies.

2.3.4 CRNBC’s Public Engagement

In its review of CRNBC, the Professional Standards Authority (PSA) found there was room for

improvement in CRNBC’s efforts to engage with patients, service users and the public and in

demonstrating that the feedback generated was being taken into account (Professional Standards

Authority, 2016). While they recognized that it was challenging, the PSA recommended that

CRNBC develop a strategy for increased public and patient engagement in the development and

revision of guidelines and standards.

At present, CRNBC’s principal means of communicating with the public is via the website,

however, one third of their Board members is drawn from the lay public. PSA noted that CRNBC

could look to the BC Patient Safety and Quality Council for assistance and advice on increasing

patient and public participation. In addition to engaging with other regulators or interested parties in

seeking the views of patients and the public, PSA recommended CRNBC consider conducting

surveys and literature reviews of their own into the expectations of patients and the public.


CRNBC is seen by other stakeholders to be open and engaging, seeking views and sharing

insights on a regular basis.

CRNBC’s existing methods of engaging the public are relatively easy to do and are common

to most public agencies and all health professional regulators. CRNBC may want to consider

new ways to engage the public, both on its own issues and on issues it shares with other

health professions regulators and health policy-makers. The McMaster Health Forum

approach presents an excellent model to learn from.




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A Town Hall style public engagement forum could both raise public awareness of their roles

and functions and generate valuable insights for CRNBC and other health regulators.

Partnering with other stakeholders could present a cost-effective and higher profile public

engagement opportunity.

While the creation of an effective “public input panel” may be time-consuming, it may offer

the most effective input for CRNBC regarding public expectations. The Patient Voices

Network presents an excellent resource to draw on in terms of learning how to engage

patients.

3. Discussion

As succinctly put by social scientist Julien Etienne, “[s]ince regulation is meant to steer behaviour

in particular directions, it always requires some sort of answer to two basic and interrelated

questions:

1. Why do people behave the way they do?

2. How can behaviour be influenced?” (Etienne, p38)

While these questions are being addressed with increasing interest by policy-makers around the

world, such as the Australian Public Service Commission in addressing “wicked problems” and the

UK Institute for Government seeking to improve the effectiveness of social policies, there remains

little attention to the questions of whether and how existing regulation affects behaviour (Sutherland

and Leatherman, 2006; Quick 2011).

Although it is well recognized that “[h]ow people behave is determined by many factors and is

deeply embedded in social situations, institutional contexts and cultural norms.” (Australian Public

Service Commission 2007a, p32) the application of insights from behavioural theory - concurrent

use of multiple avenues for influencing behaviour and prompting desired, or curtailing or preventing

undesired actions - is still in in infancy.

Recognizing the limitations of the conventional “rational person” conception of what motivates

human behaviour, the UK Institute for Government submits that “changing contexts”, shaping policy

more closely around humans’ “inbuilt responses to the world”, presents significant opportunities to

shape behaviours and practices. They present a “MINDSPACE” model that delineates the factors

that frame social behaviour.




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Exhibit 5: MINDSPACE - Influences on Human Behaviour and Change

(Institute for Government, 2015, p8)

The behaviour of those working in healthcare is shaped by multiple different “regulatory frames of

reference” operating simultaneously at any given time. These may invoke “hard” instruments, such

as rules and regulations to compel certain behaviours or they may create a referential construct that

guides or delimits behaviour.

For professionals these frames of reference include professional regulation but also the professional

persona itself, one that takes shape “[f]rom the first day of a student’s professional training”.

Through the all-too-often “uni-professional” education process, health professionals are “inoculated

with a preferred set of perceptions that define aspects of health, well-being, and the appropriate

means for achieving this status. These interactions are intimately tied to both a student’s developing

sense of professionalism and their constructed view of the world. It will influence their perceptions,

attitudes, and behaviors.” (Khalli, Orchard, Laschinger, & Farah, 2013; Pecukonis, 2014. P60).

While there are many other factors that shape their behaviour, the influence of the normative signals

internalized within professional self-conception cannot be understated. As noted by Quick in his

review of the evidence on the effects of health professional regulation on those regulated, “the

narratives authored by dominant professions have the power, in the medium and long term, to

challenge policy-makers’ and managerial attempts to regulate them” (Quick, 2011. p11). He

concludes that “the clear message to emerge from a number of studies is that regulation (however




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well intentioned) is far more likely to be complied with when accepted as legitimate by

practitioners.” (Quick, 2011, p3).

Counselling the use of ‘responsive regulation’, Healy and Braithwaite (2006), too, make the case

that “regulators are more likely to succeed if they use strategies that are responsive to the culture of

those being regulated…. Responsive regulation is an approach that values trust, transparency and

professionalism. It aims to transcend the polarised choice between punishment and persuasion”

(Healy and Braithwaite, 2006, pS56).

As Etienne notes, “…the emerging consensus in regulation scholarship is that the regulated are best

understood as having ‘multiple selves’, i.e. as following several different and not necessarily

compatible goals most of the time …. Regulatees generally have dispositions that point towards each

of many different motivations, but these dispositions are not necessarily focal or active. They may

rather be latent, which is why they could be activated, by regulators or other stimuli” (Etienne,

2011, p42)

Quick concludes that “behavioural change is much more likely when a combination of factors

conspire to convince practitioners to alter their practice. For example, if a number of sources of

influence all nudge practitioners in the same direction (e.g. terms of employment contracts, clinical

guidelines, professional regulation, professional leadership, law and financial incentives),

regulatory goals stand a greater chance of being realised” (Quick, 2011, p20).

And so, there can be no doubt of the limits to regulatory mechanisms used in isolation: context and

human behaviour must be accounted for. However, there is a question of where the responsibility for

ensuring the appropriate uptake and application of regulatory mechanism resides.

Clearly, as outlined in the right-touch decision tree (Professional Standards Authority, 2015), there is

an expectation that the regulator, or the generator of the mechanism in question, verify the need for

regulation and, according to right-touch principles, ensure that the product is understandable and

applicable in general terms. However, the conditions under which the product is employed or

deployed may be better managed “closer” to the where the issue and its associated risks appear.

Indeed, in their “Thought Paper” for the UK’s Health Foundation, Douglas Bilton and Harry Cayton

point out that “[i]n order to understand how regulation can use its power and influence most

effectively, we need to seek to understand how it can do so from its position within the architecture

of care, in a relationship with many of its registrants that is geographically and perhaps

psychologically distant but a relationship which is, nonetheless, mandatory for all.” (Bilton and

Cayton, 2013, p7)

Bilton and Cayton note the complexity of the regulatory landscape for healthcare, one that is

characterized by many different players which have sprung into being, at different times, under

different political mandates, and in the face of different socio-economic realities, to regulate “people,

places, products, prices and procedures” (Bilton and Cayton, 2013, p5). The result is a “jigsaw or a

London Underground style flowchart” in which whether the players “ do or do not relate to each




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other has been largely dependent on the organisations themselves building relationships with others

where necessary or expedient, often driven by the efforts and leadership of individual members of

staff” (Bilton and Cayton, 2013, p5). This has resulted in a situation where there are so many

sources of advice on when and how to act that there cannot help but be confusing, if not conflicting,

direction presented.

Malcom Sparrow (2012) submits that for regulation to be effective in addressing an issue, the risk

needs to be precisely identified and assessed for degree of harm, and for who is best placed to

address it, applying the tools and mandates available to them, to be identified. There are multiple

different structures for managing different types of risk and any given structure will fail if it is

applied to the wrong set of risks. Multiple different regulatory structures need to work together to

cover the domain effectively.

…it makes sense to ask, “for this type of problem, who should be responsible for what?” Who is

best placed to identify emerging patterns and trends? Who has a vantage point at the right level—

not too high and not too localized—and the relevant data or monitoring capabilities that will

enable them to spot emerging trouble, of this type, in a timely fashion? Who is best placed to

analyze and understand an emerging risk, and to propose suitably tailored interventions? Which

parties within the community can be trusted to play their part because it is in their interests to do

so, and which parties must simply be told what must be done and forced to comply … because

their private interests relating to this type of risk simply do not align with public purposes? Also,

which parts of the community should be consulted in the analysis and design phase because of the

special insights they might have into the genesis or dynamics of specific crime problems?

(Sparrow, 2012, p354)

Bilton and Cayton propose that regulators “work together to create a regulatory system which

minimises the multiplicity of different sources of guidance and direction, which is consistent and

clear, and which can be seen to be a single regulatory force with different elements. In this way, we

believe that regulators can exert beneficent influence on the behaviour of registrants from their

position within the system.” (Bilton and Cayton, 2013, p9)

Working with its concept of MINDSPACE, the UK Institute for Government has mapped the tools

for shaping human behaviour against “6 Es” – encourage, engage, exemplify, enable, explore and

evaluate – to produce a framework for application of mechanisms or influences on human behaviour.

This framework presents a potentially useful point of reference for assessing the contribution and

complementarity of the various mechanisms at work in the “pluralistic regulatory environment”

identified by Quick (2011) and others.




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Exhibit 6: Framework of Influences on Human Behaviour

(Institute for Government, 2015, p49)




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4. Conclusions

CRNBC is one of many players in the healthcare environment concerned with regulating “people,

places, products, prices and procedures” with multiple different – and sometimes confusing and

possibly conflicting – regulatory frameworks. Contemporary conceptions of right-touch regulation

indicate that it should be:

• Proportionate: regulators should only intervene when necessary. Remedies should be

appropriate to the risk posed, and costs identified and minimised

• Consistent: rules and standards must be joined up and implemented fairly

• Targeted: regulation should be focused on the problem, and minimise side effects

• Transparent: regulators should be open, and keep regulations simple and user friendly

• Accountable: regulators must be able to justify decisions, and be subject to public

scrutiny

• Agile: regulation must look forward and be able to adapt to anticipate change

(Professional Standards Authority, 2015, p4).

Given the complexity of the healthcare regulatory environment, CRNBC needs to carefully consider

the contribution it is able to make in shaping registrants’ practice. While the influence of human

behaviour and context in constraining the effectiveness of professional regulation bears noting, it

may not be appropriate or even possible for CRNBC to play a significant role in managing these

influences. It may be fruitful for CRNBC to engage with other players to identify respective roles

and responsibilities in the context of a broad conception of regulation and in consideration of the

various regulatory instruments available to address any given concern.




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APPENDIX A: KEY INFORMANTS

Organization Name Title

College of Physicians and Surgeons of British Columbia

Heidi Oetter Registrar

College of Nurses of Ontario Anne Coghlan Kevin McCarthy Erin Tilley Rola Moghabghab

Executive Director & CEO Manager, Strategy Policy Analyst, Strategy Advanced Practice Consultant, Practice Standards Team

College of Veterinarians of Ontario Jan Robinson Registrar & CEO

National Council of State Boards of Nursing; Chicago, Illinois

David Benton Kathy Apple (retired)

CEO Past CEO

Professional Standards Authority Douglas Bilton Research & Knowledge Manager

College of Licensed Practical Nurses of BC

Carina Herman, Wendy Winslow, Janice Harvey

Executive Director

College of Registered Psychiatric Nurses of BC

Fiona Ramsay Colleen Calderwood

Credentials Manager Practice Manager

McMaster Health Forum John N. Lavis Professor, Department of Clinical Epidemiology & Biostatistics

College of Physicians and Surgeons of Saskatchewan

Dennis Kendel (retired)

Past Registrar

Access Consulting Ltd. Steven Lewis President

BC Nurses' Union Patricia Wejr Director of Communications Systems and Policy Advisor

BC Patient Safety Council

Christina Krause Doug Cochrane

Executive Director Chair & Provincial Patient Safety & Quality Officer

Canadian Patient Safety Institute Chris Power Chief Executive Officer

Chartered Professional Accountants of BC

James Midgley EVP, Regulation and Registrar




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Tim Porter-O'Grady Associates, Inc. Tim Porter-O'Grady Senior Partner

University of Western Ontario, Faculty of Health Sciences

Sandra Regan Associate Professor

Patient Voices Network Ben Ridout Director, Patient & Public Engagement

Consultant Jo Wearing

BC Ministry of Health Lynn Stevenson Associate Deputy Minister - Health Services

CRNBC Daryl Beckett

External Focus Groups

Chief Nursing Officers (CNOs)

HPA Leads Emma Gibson (PHSA) Maneet Samra (Fraser) Wendy Bowles (Fraser) Paula Araujo (Interior) Helen Bourque (NH) Natasha Prodan-Bhalla (BCCWH-PHSA) Julie Carleton (Providence) Cynthia Clark (VCH)

CRNBC Staff Focus Groups

Policy

Barb Willson

Lorna Roe

Chris Daly

Monica Redekopp

Alison Wainwright

All Staff Focus Group 1 - June 13, 1300-1500

Yukari Sumita David MacDonald Jacinta MacKinnon Rekha Singh

All Staff Focus Group 2 - June 15, 1400 to 1600

Caroline Howe

Daryl Beckett

Johanna Ward

Joyce Black

Jane Winder

RN/NP Leads Focus Group - June 16, 1300-1500

Emma Gibson

Louann Janicki

Maneet Samra

Wendy Bowles




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Paula Araujo

Helen Bourque

Natasha Prodan-Bhalla

Julie Carlton




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APPENDIX B: INTERVIEW GUIDE

Review of Policy Processes and Products

Interview Guide

Background: As part of an effort to clarify understanding of the College of Registered Nurses of BC’s (CRNBC)

public protection mandate, CRNBC is reviewing its existing suite of programs to ensure they are in

keeping with contemporary trends and best practices for professional regulatory bodies and that they

are aligned with their recently approved strategic plan and philosophical framework.

The focus of this review is on CRNBC’s regulatory policy process and products and opportunities

for improvement.

The review includes consultations with stakeholders internal and external to CRNBC, a review and

analysis of the literature related to policy processes and products within the regulatory environment,

and interviews with key informants. The objectives of the review are to:

better understand stakeholder perspectives on the current process and products, their value

and opportunities for improvement;

identify relevant trends affecting regulatory policy development processes and products; and

identify the key regulatory policy processes and products that CRNBC should consider in

addressing its mandate of protection of the public into the future.

Thank you for agreeing to participate as a key informant. The ideas and questions in this

document will be used to guide the interview. Although some of your comments may be

captured and reported verbatim in a final report of the findings, nothing you say will be

for attribution and nothing reported will be traceable to any individual key informant.

Focus of the Review: This review focuses on CRNBC’s Policy, Practice and Quality Assurance (PPQA) department,

specifically the development of policy to guide nursing practice, and the sharing, education and

dissemination of policies to registered nurses and nurse practitioners to inform, direct and guide their

practice. The main policy products in use by CRNBC include

Standards of Practice

Limits and Conditions on scope of practice

Regulatory Mechanisms such as named agency and additional education.

Interview Questions:

1. Please describe your familiarity with CRNBC’s policy processes and products?




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2. From what you know about CRNBC’s policy process or processes employed by others…

2a.What works well?

2b. What needs to be improved and why?

2c. Are CRNBC’s existing policy processes and products effective in protecting the public?

2d. If not, why not?

2e. If so, which processes or products have the best outcomes?

3. From what you know about CRNBC’s policy products (Standards, Limits and Conditions and

regulatory mechanisms such as ‘named agency’) or products employed by others (please identify

these products)…

3a. What is the value of these products?

3b. What works well?

3c. What needs to be improved and why?

3d. Are the mechanisms employed by CRNBC necessary today?

3e. Are they necessary when new regulations or new authorities are being implemented?

4. In your experience, what are the best approaches for including nurses and the public in policy

development processes?

4a. What is the value of greater inclusivity?

4b. What are the costs?

5. What do you see as current best practice with respect to policy process and products?

6. What future-oriented processes/products might be considered?

7. What emerging trends and issues may affect future practice with respect to policy process and

products?

8. Do you have any additional thoughts about policy process or products, or any references or

resources to share that will help to deepen our understanding?

Thank you for taking the time to share your views and expertise with us.




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APPENDIX C: REFERENCES

Australian Public Service Commission. (2007a) Changing Behaviour: A Public Policy Perspective.

Commonwealth of Australia.

Australian Public Service Commission. (2007b) Tackling Wicked Problems: A Public Policy

Perspective.

Commonwealth of Australia.

Australian Public Service Commission. (2009) Smarter Policy: choosing policy instruments and

working with others to influence behaviour. Commonwealth of Australia.

Bilton, Douglas and Cayton, Harry. (2013) Asymmetry of influence: the role of regulators in patient

safety. The Health Foundation.

Black, Julia, Critical Reflections on Regulation. (2002) Australian Journal of Legal Philosophy, (27)

1-35

Black, Julia and Baldwin, Robert. (2010). Really Responsive Risk-Based Regulation. Law and

Policy. Vol 32 Issue 2. 181-213

Calman, Kenneth. (1994) The profession of medicine. BMJ , 309:1140-3

Council for Healthcare Regulatory Excellence. (2011) Patient and public participation in health

professional regulation.

CRNBC. (2015) Comparison between Regulatory Approaches: Certified Practice, Named Agency

and Additional Education.

CRNBC. (2015) Framework for Policy Development (DRAFT), February 24.

Dower, Catherine, Jean Moore and Margaret Langelier. (2013) It is time to restructure health

professions scope-of-practice regulations to remove barriers to care. Health Affairs, November

32:11, 1971-1976.

Etienne, Julien. (2011) Compliance Theory: A Goal Farming Approach. Law & Policy, Vol 33 No.

3, 305-333

Etienne, Julien. (2013) Thoughts on how to regulate behaviours: an overview of the current debate.

British Journal of Guidance & Counselling, Vol 41 No. 1, 36-45




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Healy, Judith and John Braithwaite. (2006) Designing safer health care through responsive

regulation. MJA, Volume 184 No 10. 15, S56-S59

http://www.instituteforgovernment.org.uk/our-work/better-policy-making/mindspace-behavioural-

economics

Institute for Government. (2015). MINDSPACE Influencing behaviour through public policy.

Khalli, Hossein, Carole Orchard, Heather K. Spence Laschinger, and Randa Farah. (2013) An

interprofessional socialization framework for developing an interprofessional identity among health

professions students. Journal of Interprofessional Care, 27(6). 448-453.

Lloyd-Bostock, Sally M. and Hutter, Bridget M.(2008) Reforming regulation of the medical

profession: The risks of risk-based approaches. Health, Risk & Society, 10(1), 69-83.

McMaster Health Forum. https://www.mcmasterhealthforum.org

Pecukonis, Edward. Interprofessional Education: A Theoretical Orientation Incorporating

Profession-Centrism and Social Identity (2014) Theory Journal of Law, Medicine and Ethics -

Interprofessional Global Health Education, Winter, 60-64

Professional Standards Authority (2016). A review conducted for the College of Registered Nurses of

British Columbia. April

Professional Standards Authority. (2015). Right Touch Regulation – Revised, October

Quick, Oliver. (2011) A scoping study on the effects if health professional regulation on those

regulated. Council for Healthcare Regulatory Excellence, May.

Silbey, Susan. (2011) The sociological citizen: Pragmatic and relational regulation in law and

organizations. Regulation & Governance, 5, 1-13

Sparrow, Malcolm. (2012). Joining the Regulatory Fold. Criminology and Public Policy. Vol 11

Issue 2, 345-359.

Sparrow, Malcom K. (2000) The regulatory craft: controlling risks, solving problems, and managing

compliance. Brookings Institution Press, Washington, D.C.

Spector, Nancy. Evidence-Based Nursing Regulation: A Challenge for Regulators. Journal of

Nursing Regulation Volume 1 Issue 1, 30-36

Sutherland, K and Leatherman, S. (2006) Regulation and quality improvement: a review of the

evidence. The Health Foundation.

http://www.instituteforgovernment.org.uk/our-work/better-policy-making/mindspace-behavioural-economics

http://www.instituteforgovernment.org.uk/our-work/better-policy-making/mindspace-behavioural-economics

https://www.mcmasterhealthforum.org/




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Thaler, R. and Sunstein, C. (2009). Nudge: Improving decisions about health, wealth and

happiness. Toronto, Canada: Penguin Group.

UK Institute for Government. http://www.instituteforgovernment.org.uk

http://www.instituteforgovernment.org.uk/

Documents

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