​​​Regulatory control​​s on practice framework

As a B.C. midwife, your practice limits are determined by B.C. government regulation, your regulatory college, your place(s) of practice policies, and your individual competencies.

What w​​ill I learn?​

• What is midwifery scope of practice ​​and what shapes it?
• What are the four levels of reg​ulatory control on midwifery scope of practice?

Und​erstandin​​g scope of practice

Scope of practice refers to the activities that registered midwives are educated and authorized to perform under the B.C. Midwiv​es Regulation within the Health Professions Act. The Midwives Regulation is written and approved by the provincial government.

There are two aspects of midwifery scope:

1. Midwifery profession's scope​​ of practice

All midwives must work within the midwifery profession's scope of practice. The midwifery profession's scope of practice, also called the profession's legislated scope of practice, is impacted by:

​a.	​The Midwives Regulation, and other relevant federal and provincial legislation
​b.	​BCCNM regulatory documents:​
​	​Entry Level Competencies for Registered Midwives  Standards, limits & conditions, policies, and guidelines Bylaws

2. Individual midwife's scope of pract​​ice

The individual scope of practice refers to the midwife's unique scope of practice. Each midwife's individual practice will look different. Midwives determine their individual scope of practice within their practice settings by reflecting on:

• Their education
  
• Authority to perform activities
• Their individual competence, i.e., the ability to integrate and apply knowledge, skills, and judgment for safe and appropriate performance in practice
• Policies that may restrict a midwife's practice in a practice setting (e.g., clinic, hospital, or home)​​
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​​​Regulatory controls on practice

BCCNM defines the mechanisms that authorize a midwife to perform an activity as the controls on practice. The controls on practice framework can be used as a decision support tool to help you decide if you are authorized to perform an activity for a client. A framework is useful to understand what activities are in scope, when you can perform an activity, what limits or conditions must be met to perform the activity, and the competencies required to perform an activity.

There are four levels of regulatory control on a midwife's practice. Each level, from the bottom to the top, works to narrow and define a midwife's scope of practice.

1. Regulation & legislation​​

The Health Professions Act and the Midwives Regulation broadly outline the activities midwives are authorized to perform.

For example, the Midwives Regulation sets out that midwives provide health-care services to clients during “normal pregnancy, labour, delivery and the postpartum period." Therefore, under the Regulation, a midwife is not authorized to provide care to clients who fall outside this requirement (e.g., treating a client's non-pregnant partner).

Guiding questions to help understand how regulat​​ion defines your practice:

• How does the activity fit within the legal definition of midwifery as per the Midwives Regulation?
• Does the care involve restricted activities? Are these activities within the Midwives Regulation?
• Is the activity authorized in the Midwives Regulation to my registration class?
• What other provincial or federal legislation may be relevant to my practice (e.g., Freedom of Information and Protection of Privacy Act)? 

2. BCCNM​

BCCNM bylaws, standards, limits & conditions, policies, and guidelines further define the scope of practice set out in the Regulation.

For example, before prescribing narcotics, a midwife must complete the BCCNM-approved course as set out in the Medications and Substances: Standard, Limits, Conditions. A midwife is not authorized to prescribe narcotics if the course is not successfully completed.

Guiding questi​​ons to help understand how BCCNM further defines your practice:

• What specific BCCNM standards, limits & conditions, policies, and guidelines relate to this activity?
• Is it in the clients' best interest for me to provide this care?

3. Place of practice​​

The "place of practice" can be defined as the location in which midwives provide care to clients (e.g., a clinic, hospital in which you have privileges, or independent practice setting). Practising midwives are required to know which activities they are authorized to perform in their place of practice as these policies may restrict or define the practice of midwives in a particular location.

For example, some hospitals policies may restrict midwives from performing an activity like water births, even if midwives have the skills and knowledge to perform it, or have performed it at another place of practice.

Guiding questions to help understand how​​ place of practice policies define your practice:

• Do the place of practice policies authorize me to perform the activity?
• Do my privileges include the activity to be performed?
• Are there resources to support me before, during, and after the activity?

4. Individual competen​ce

An individual midwife's competence to carry out a particular activity may further define a midwife's scope, with competence being the integration and application of the professional attributes (knowledge, skills, and judgment) required to perform in a given role, situation, or practice setting.

An individual midwife determines whether they have the necessary competence to safely perform an activity for their client and whether they can appropriately manage the outcomes of care in their practice setting. If a midwife has not acquired the competence to perform an activity, they have a duty not to perform it. For example, a midwife is only authorized to treat sexually transmitted infections (STIs) by successfully completing the specialized practice certification requirements.

Guiding questions to under​​stand how individual competence defines your practice:

• Do I have the competence to carry out the activity safely and appropriately? (i.e., Do I have the knowledge, skills, and judgment to: assess the appropriateness of performing the activity; perform the activity; and manage the client before, during, and after the activity?)
• How will I gain and maintain my competence?
• Can I meet the relevant BCCNM standards of practice, policies, and guidelines and place of practice policy requirements related to this activity?
• Am I the most appropriate care provider?
• If required, do I have the additional practice certification needed to perform the activity?
  
  

​​Controls on pr​​act​ice framework in action

Scen​​​​ario:

Nancy is a midwife. Her client is in active labour and admitted to the local hospital. Her client is struggling to cope in labour and is requesting acupuncture for pain management. Nancy determines that acupuncture is an option for her client.

Is Nancy is autho​​rized to perform this activity?

Level 1 – Regulation & legislation

Nancy reviews t​​he Midwives Regulation for this activity. She finds that midwives may “insert acupuncture needles for the purpose of pain relief during labour or the postpartum period" (for a person during normal pregnancy, labour, delivery, and the postpartum period). Based on this information, if she completes BCCNM-approved training, she is authorized by the Regulation to provide acupuncture to her client.

Level 2 – BCCN​​M

Nancy knows that ​​BCCNM has the authority to further define all registrants' scope of practice in the Midwives Regulation. Reviewing BCCNM's requirements on acupuncture, she learns that BCCNM considers acupuncture a specialized practice that requires certification. She also learns that a midwife may insert acupuncture needles only during labour or in the immediate postpartum period (i.e., the first 24 hours following birth). Therefore, in order to provide acupuncture, a midwife must first successfully complete the BCCNM-approved course. Nancy has successfully completed the requirements as outlined in BCCNM's  Framework for midwife certification in acupuncture use in labour and in the immediate postpartum.

Level 3 – Place of p​​ractice

Nancy is aware​ that place of practice policies may further define a midwife's scope of practice but cannot expand scope beyond what the Midwives Regulation and BCCNM outline.

Nancy reviews the hospital's Department of Midwifery policies regarding acupuncture use by midwives and finds there are additional limitations on midwifery practice in this setting; the hospital allows midwives to add acupuncture use to their non-core privileging dictionary and defines the parameters regarding initial privileges, renewal of privileges, and return-to-practice requirements.

Nancy has added acupuncture to her non-core privileging dictionary and her hospital privileging is current.

Level 4 – Indi​​​vidual competence

Nancy is awa​​re that individual midwives work within the parameters of the Midwives Regulation, BCCNM, place of practice, as well as their individual scope of practice and competence.

Nancy knows she has the necessary knowledge, skills, and judgment to safely perform acupuncture for her clients. She has maintained this certification and she is confident she can provide safe and competent care to Beth.

Nancy's de​cision

After considering the controls on practice and how they define her practice, Nancy determines she can carry out acupuncture for her client, as she meets the requirements at all of the levels of the controls on practice.