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Appendix A

College of Paramedics of Nova Scotia Consultation Strategy

Background Document

This document has been developed for the purpose of communicating, educating and creating awareness around the

College’s proposed key concepts for amending the Paramedics Act and Regulations. This kit provides more detail regarding the regulatory amendments being sought by the College including the areas of the legislation where

amendments are being sought, the rationale for the proposed amendment, the current legislative language and finally the proposed changes.

The Background Document will be accessible to all stakeholders during the consultation process.

CPNS Consultation Strategy – Appendix A

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TABLE OF CONTENTS

Overview of Challenges with the current legislation…………………………………………..…4 How the proposed amendments serve the public interest……………………………………...4 Principles that shaped the proposed changes…………………………………………………….5 Moving forward with the Consultation Process…………………………………………………...6 Areas for Proposed Changes Mandate Objects of the College (Key Concepts/Rationale) …………………………………………...7 Registrant Definition (Key Concepts/Rationale) ……………………………………………..8 Standards of Practice Definition (Key Concepts/Rationale) ………………………………..9 Governance Name of Governing Body (Key Concepts/Rationale) ……………………………………...10 Board Composition (Key Concepts/Rationale) ……………………………………………..10 Role of the Board (Key Concepts/Rationale) ……………………………………………….11 Board Elections and Administrative Matters (Key Concepts/Rationale) …………………13 Public Representatives on Statutory Committees (Key Concepts/Rationale) …………..16 Scope of Practice

Practice of Paramedicine Definition (Key Concepts/Rationale) …………………………..19 Expanded Scope of Practice Definition (Key Concepts/Rationale) ………………………24 Registration and Licensure Revised Committee Names (Key Concepts/Rationale) ……………………………………27 Revised and New Definitions (Key Concepts/Rationale) ………………………………….27 Classes of Licenses (Key Concepts/Rationale) …………………………………………….28 Waiver Provision (Key Concepts/Rationale) ………………………………………………..29 Registration and Licensure Process (Key Concepts/Rationale) ………………………….30 Absence of a License (Key Concepts/Rationale) …………………………………………..31 Registration Criteria (Key Concepts/Rationale) …………………………………………….32 Class of Licensure Criteria (Key Concepts/Rationale) …………………………………….33 Professional Conduct Revised Definitions (Key Concepts/Rationale) ……………………………………………..36 Investigations and Hearings (Key Concepts/Rationale) ………………………….............38 Fitness-to-Practise (Key Concepts/Rationale) …………………………………………………….39 Quality Assurance Initiatives (Key Concepts/Rationale) ………………………………………..40 Protected Titles (Key Concepts/Rationale) ………………………………………………………...41 Custodians (Key Concepts/Rationale) ………………………………………………………………42


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OVERVIEW OF CHALLENGES WITH CURRENT LEGISLATION

The College of Paramedics of Nova Scotia is seeking government approval for revisions to the Paramedics Act and will be consulting stakeholders on the proposed amendments. The current Paramedics Act, SNS 2015, c 33 (“the Act”) was passed in 2015 and proclaimed in force on April 1, 2017. The process undertaken for the development of the content of the Act is somewhat unclear, as the Act appears to contain extracts from a number of professional self-regulation statutes in effect at that time. Some of the statutes that may have formed the precedents for the Act have since been significantly amended. Those who currently administer the Act, including the Council of the College, Committees, the Registrar and staff, have found a number of issues that are creating difficulties in its implementation. A Legislation Review Committee has met regularly over the course of more than a year to review the Act and its Regulations and to prepare recommendations to the Council of the College for revisions. Council met in October 2019 to approve the recommendations from the Committee and to authorize the advancement of the proposed revisions to government.

HOW THE PROPOSED AMENDMENTS SERVE THE PUBLIC INTEREST

The proposed amendments to the Paramedics Act are designed to better serve the public interest in several ways, including:

▪ changing various terms used throughout the existing legislation, in order to provide better clarity and consistency with terms used in other Nova Scotia statutes;

▪ containing flexible language that will allow the paramedic scope of practice to evolve as the profession evolves, without the need for statutory change;

▪ removing the requirement for paramedics to practise under the direct or indirect supervision of a medical practitioner. This requirement has presented considerable problems in practice.

▪ enabling an expanded scope of practice for paramedics with certain classes of

licences, to provide services normally reserved for those with other classes of licences, where the need exists and where the paramedic has had appropriate education and training.

▪ amending the mandate (objects) by reinforcing the need to regulate paramedicine in the public interest. The mandate will contain specific reference to the need for accountability from the College to the Minister of Health and Wellness, the public and to all who are regulated by it. Further, the new Act will expand the objects of


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the College to include the regulatory role of approving education programs for paramedicine.

▪ deleting a section of the current Act that suggests it is the role of the Council to examine applicants applying to be licensed, and to issue licences. These functions are not performed, and should not be performed, by Council;

▪ moving internal matters – such as election processes and frequency of Council – meeting to College bylaws or policies, which will allow for adaptability and improvement without the need for statutory changes;

▪ streamlining classes and categories of licensure;

▪ clarifying the respective roles of the Registrar, the Registration and Licensing Committee, and the Registration and Licensing Review Committee;

▪ clarifying and simplifying the registration and licensing criteria;

▪ embedding flexible regulation making language that permits the development of regulations respecting the development and implementation of a Quality Assurance Program;

▪ revising the investigation and hearing processes to allow for a consistent approach with other health professions. The revised provisions are designed to be flexible, enabling, fair to the complainants and registrants, and offer appropriate transparency to the public; and

▪ revising and improving the fitness-to-practise process to align with other health professions.

PRINCIPLES THAT SHAPED THE PROPOSED CHANGES

In preparing the proposed changes, the Legislation Review Committee was guided by certain principles that shaped the outcome of their work. These principles are as follows;

1. The legislation should reflect the current reality of the practice of paramedicine in Nova Scotia, and the anticipated evolution of the profession;

2. Statutory language should be enabling, to provide flexibility as the profession matures from a regulatory perspective;

3. To the extent other health professions in Nova Scotia have adopted changes to their

legislative structure that are transferable to the regulation of paramedicine, consistency should be sought with these other statutes.


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4. Amendments should be informed by the legislation in place for the other jurisdictions in Canada where there is comparable self-regulation of the paramedic’s profession, i.e., Alberta, Saskatchewan, Manitoba and New Brunswick.

5. The amendments should adopt where appropriate the principles set out in the government’s Policy on Self-Regulation.

6. The legislation should be consistent with Nova Scotia’s Fair Registration Practices Act.

7. Amendments should enable processes and practices that will better meet the health

system needs of Nova Scotians in a timely way.

8. Procedures for various regulatory roles such as registration, licensing, investigations and hearings, should use clear, unambiguous language.

MOVING FORWARD WITH THE CONSULTATION PROCESS

The intent of the College is to embark on a consultation process with all relevant stakeholders in early 2020, to obtain feedback on the various proposals outlined in this submission. That feedback will then be provided to government for further direction with respect to final concepts for inclusion in the amendments. The College is requesting government introduce the proposed amendments in the fall of 2020 preferably, with a fall back of the spring of 2021. The College appreciates the time and attention of all who participate in the consultation process and looks forward to receipt of feedback to assist in creating new legislation that will meet the objectives outlined above.


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1.0 MANDATE A. Objects The College’s existing objects reflect the public-interest mandate of the College, but this could be enhanced by ensuring that some of the secondary objects are always subject to the public interest. Recent reviews of the regulation of various professions in Canada emphasize the importance of reinforcing the public interest and patient safety so there is no confusion about regulatory versus membership objectives. The revised mandate should also contain specific reference to the need for accountability from the College to the Minister of Health and Wellness, the public and to all who are regulated by it. This is consistent with the government’s policy on self-regulation. The current objects clause in the Paramedics Act contains a subsequent section in terms of specific matters the College must do in order to effectively carry out its objects. This section currently does not address the regulatory role of approving education programs for paramedicine. While the regulations under the current Act notes that Council sets the criteria for paramedic programs, this is a sufficiently important regulatory function that it should be included in the Act itself. Further, section 4(2)((a)(iii) of the current Act references that the regulatory functions of the College include the establishment of the standards of practice, and a continuing professional development program, but neglects to mention the College’s role in approving the competencies for paramedics. There is a section in the current regulations that addresses the setting of competencies, but given the importance of competencies, it is preferable to move this function into the objects section of the Act. To give effect to these changes, the proposed concept is as follows:

Objects

Current Proposed Concept

4(1) The objects of the College are to (a) serve and protect the public interest in the practice of paramedicine; (b) preserve the integrity of the paramedic profession; and (c) maintain public and member confidence in the ability of the profession to regulate the practice of paramedicine. (2) In order to effectively carry out the objects of the College, the College shall (a) regulate the practice of paramedicine and govern its members through

(1) The objects of the College are to (a) serve and protect the public interest in the practice of paramedicine; (b) subject to the public interest:

(i) preserve the integrity of the paramedic profession, and

(ii) maintain public and registrant confidence in the ability of the profession to regulate the practice of paramedicine.

(c) be accountable to the Minister, the public and the registrants; and


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Objects


(i) the registration, licensing, professional conduct and other processes set out in this Act and the regulations,

(ii) the approval and promotion of a code of ethics, and

(iii) the establishment and promotion of

(A) standards for the practice of paramedicine, and (B) a continuing professional development program; and

(b) do all such other lawful acts and things as are incidental to the attainment of the objects and purpose.

(d) do all such other lawful acts and things as are incidental to the attainment of the objects of the College. (2) In order to effectively carry out the objects of the College, the College shall (a) regulate the practice of paramedicine and govern its registrants through

(i) the registration, licensing, professional conduct, education approval and other processes set out in this Act and the regulations,

(ii) the approval and promotion of a code of ethics, and

(iii) the establishment and promotion of

(A) standards for the practice of paramedicine, (B) a continuing competence program, and (C) entry-level and other competencies;

(b) do all such other lawful acts and things as are incidental to the attainment of the objects and purpose.

Taken as a whole, the proposed amendments to the Act’s objects underscore the regulatory nature of the College and highlight its key regulatory functions which are necessary for public protection and patient safety. B. New Definition - “Registrant” In the current Act, “member” is the term used to refer to persons who are registered and licenced with the College. Although paramedics may be “members” of the College, they do not possess the same rights as are understood in a traditional membership organization. In a traditional membership organization, such as a professional association, members have the right to vote for their own


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self-interest. However, in an organization engaged in self-regulation such as the College, members must always act in the public interest. There is a concern that the continued use of the term “member” will contribute to a misconception that the College serves the interests of its members, not the interests of the public. Using the term “registrant” can help overcome this misconception. The proposed amendment replaces the term “member” with the term “registrant” throughout the Act and is defined as persons who are registered with the College. This proposed amendment is consistent with changes made to other recent legislation for professions in Nova Scotia, such as the new Nursing Act. Further, the Medical Imaging and Radiation Therapy Professionals Act, which is waiting proclamation, defines persons registered with the College as “registrants”, rather than “members”.

“Registrant”


s.2 (w) “member”, unless the context otherwise requires, means a person whose name is entered in the Register.

“registrant” means a person whose name is entered in the Register

C. New Definition - “Standards of Practice” In the definition of "standards of practice", the reference to "entry-level professional practice expectations" for any registrant should be revised to remove the words "entry-level", to reflect that standards apply across all levels of experience and practice.

“Standards of Practice”


(zl) "standards of practice" means the entry-level professional practice expectations for any member in any setting or role, approved by the Council or otherwise inherent in the profession.

"standards of practice" means the professional practice expectations for any member in any setting or role, approved by the Council or otherwise inherent in the profession.


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2.0 GOVERNANCE

A. Name of Governing Body Currently, the College is governed by a “Council”. The proposed amendment is to name the governing body of the College the “Board”. Within the 22 health professions regulators in Nova Scotia, there are examples of both Boards (e.g. nurses, chiropractors, occupational therapists, dentists, physiotherapists) and Councils (e.g. physicians, pharmacists, medical radiation technologists). However, the majority call their governing body a board. The use of the term “board” carries with it a greater governance focus and the attendant fiduciary responsibilities that come with being board members. It removes the sense of “constituency” that comes with a person elected as a Council member, where there can be tendency of thinking of a Council member as one that needs to be responsive to the constituency that elected that member, rather than to the organization and its broader public interest purposes.

Governing Body


“Council”

“Board”

B. Board Composition With respect to the composition of the Board, rather than fixing the number of Board members in an unchanging way in the Act, it is recommended that flexible language be used to leave room for evolution in the future. There is merit in having a minimum number specified for Board composition, to ensure that the appropriate profile of competencies exists to govern the College. Consistent with literature on good governance practices and other recently amended statutes in Nova Scotia such as the Nursing Act, it is recommended that the minimum number be somewhere in the range of 7-12. After considering the regulatory functions of the College and the workload experienced to date, it is recommended that the minimum number be 10 Board members, where the number of public representatives should be not less than a third, and not more than half of the full Board.

Board Composition


7 (1) Subject to subsection 105(2), the Council consists of (a) eight members of the College who

(i) hold active practising status as paramedics,

The Board shall consist of (a) a minimum of 10 persons; (b) the number of public representatives on the Board must be not less than 33% and not more than 50% of the Board;


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Board Composition

(ii) are elected by the members of the College, (iii) are members in good standing, and (iv) represent the geographical districts and classes of licence set out in the by-laws; and

(b) four public representatives appointed by the Governor in Council.

(c) public representatives on the Board are appointed by the Governor in Council; (d) members, other than public representatives of the Board, are elected or appointed as prescribed in the by-laws and policies approved by the Board.

The proposal for Board composition outlined above will:

• be consistent with government’s Self-Regulation Policy;

• permit maximum flexibility if circumstances change and a higher number of Board members is required;

• allow for 33% to 50% proportion of public representatives;

• be consistent with recently amended legislation;

• create a manageable size from which to foster active board engagement during meetings; and

• enable fair distribution of committee work. C. Role of the Board Subsection 6(2) of the current Act suggests that it is the role of the Board to examine applicants applying to be licensed, and to issue licences. Further it states the Board is to maintain a Register, and to hear complaints and issue licensing sanctions. Despite this statement, these roles under the current Act are not in fact performed by the Board, and they should not be performed by the Board. This section of the legislation should be deleted to ensure that the Board’s role is one of governance, not operations. Subsection 6(3) of the current Act which sets out some of the specific roles of the Board should be revised to more accurately reflect its governance functions.

Operational role of Board


6(2) To more effectively carry out the objects of the College and the purpose of this Act, the Council may (a) examine applicants applying to be licensed;

Removed from Act.


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(b) issue or cause to be issued licences to persons who by this Act and the regulations are qualified to practise paramedicine; (c) establish and maintain the Register; (d) hear complaints against members and administer disciplinary procedures through the Council's disciplinary committees; (e) suspend, revoke, restrict or refuse to renew licences; and (f) review the operation of this Act and the regulations and make recommendations thereon.

6(3) In addition to any other power conferred by this or any other Act, the Council may do such things as it considers appropriate to carry out the objects of the College and, without limiting the generality of the foregoing, may (a) engage such agents and employees as it, from time to time, considers expedient; (b) expend the money of the College in the advancement of its objects in such manner as it considers expedient; (c) establish and maintain such offices and agencies as it considers expedient; (d) invest and deal with any money and funds of the College that are not immediately required, in such manner as it considers expedient; (e) borrow money for the use of the College on its credit, limit or increase the amount to be borrowed, issue bonds, debentures, debenture stock and other securities on the credit of the College and pledge or sell such

In addition to any other powers conferred by this or any other Act, the Board shall govern the College and in so doing shall (a) set fees payable by applicants and registrants; (b) determine the remuneration and reimbursement for expenses payable to board and committee member; (c) approve the processes for setting, revising and monitoring the annual budget; (d) submit an audited financial statement of the College's operations for the past year at the annual meeting of the College; (e) appoint an auditor who shall audit the accounts of the College; (f) set the form and amount of professional liability insurance or other form of malpractice coverage or liability protection the registrants must have; (g) approve paramedic education programs; (h) approve standards of practice, competencies and a code of ethics for all registrants;


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securities for such sums or at such prices as it considers expedient; (f) secure the repayment of money borrowed, in such manner and upon such terms and conditions as it considers fit, and, in particular, by the execution and delivery of mortgages of all or any part of the real or personal property of the College, both present and future; and (g) do such things as are incidental to or necessary for the exercise of the powers referred to in clauses (a) to (f).

(i) establish governance policies consistent with the Act and the regulations; (j) review the operation of this Act and Regulations and make recommendations thereon; (k) do such other things as may be incidental to or necessary for the exercise of the objects of the College.

D. Board elections and administrative matters The current Act contains provisions that relate to the details of the election process for Council members, their terms of office, frequency of meetings, and other issues that relate to the internal operations of the College. These kinds of internal matters more properly belong in bylaws or policies, which can be changed without the need for government involvement. For example, there may need to be an evolution beyond geographical representation for Board composition to ensure that the Board has the necessary competency profile to conduct its governing functions.

Board elections and administrative matters


7(2) A member of the Council elected pursuant to clause (1)(a) who moves to a district or class of licence other than the district or class of licence the member was elected to represent (a) may complete the member's term on Council; and (b) subject to subsection 8(4), may re-offer for re-election in the district or under the class of licence the member then practises in. (3) Members of the Council must be elected or appointed to office in such manner as the by-laws set out or as set out in regulation.

Removed from Act and relocated to bylaws or policies.


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8 (1) For the purpose of this Section and Section 11, two terms are consecutive if the second term commences 12 or fewer months after the first term ends. (2) Subject to subsection 105(2), persons elected or appointed as members of the Council hold office for a term of three years. (3) Notwithstanding anything contained in this Section, persons appointed by the Governor in Council hold office until their successors are appointed or until they are re-appointed. (4) No person may be a member of the Council for more than two consecutive terms.


9 Every practising member in good standing is eligible to vote in an election of the Council and to be nominated as a candidate for membership on the Council.


10 A member may in such manner as the by-laws set out petition the Council against the election of a person to the Council.


11 (1) The Council shall elect annually from among its members a President and a Vice-president. (2) The Council may elect annually such other officers for the Council and for such terms of office as the Council considers necessary to assist it in carrying out its duties pursuant to this Act.



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(3) No person may be elected President or Vice-president for more than two consecutive terms. (4) Where an officer of the Council resigns or otherwise ceases to hold office before the expiration of the officer's term, the Council shall appoint a person from among its members to hold such office for the balance of the unexpired term.

17 The Council shall meet at least four times in each calendar year at such time and place as the Council determines.


18 Except in the event of an equal number of votes being given for and against a resolution at any meeting, the President or other presiding officer may not vote.


19 The Council may appoint from time to time such committees from among members of the Council or the College as the Council considers necessary to assist it in carrying out its duties pursuant to this Act.


20 (1) Subject to subsection (2), the President shall preside at all meetings of the Council and of the College. (2) Where the President is absent from a meeting, the Vice-president or, in the Vice-president's absence, some other member of the Council chosen by the members present shall preside at the meeting.


Taken as a whole, the proposed governance amendments provide several benefits, including increased public interest focus and accountability, and continued flexibility.


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Maintaining specific board composition matters in the by-laws will enable the College to remain current with respect to evolving best practices in governance.

E. Public Representatives on Statutory Committees Nova Scotia’s Policy on Self-Regulation provides that statutory committees should include at least one of the public representatives appointed by government. The current Act does not contain any requirements for public representatives to also be appointed to statutory committees reviewing registration decisions or investigating or disciplining registrants. The College requests that this requirement not be imposed on it when it seeks amendments to its current Act.

Proposed Concept - Policy on Self-Regulation Requested Waiver

Public Representatives on

Statutory Committees

Public representatives on the Board not be required to sit on adjudicative committees

The first difficulty with the Policy requirement is that not all statutory committees are the same. In particular, there is a distinction between those committees which do initial regulatory work for the profession, making initial decisions on registration/licensing, and investigating complaints, compared with other committees which perform formal adjudicative functions involving two parties. Registration appeals, and formal disciplinary hearings fall into the latter category. For purposes of this submission, these latter committees are referred to as “adjudicative committees”, and the former committees as “initial decision-making committees”. The initial decision-making committees are the Registration Committee, Investigation Committee and the Fitness to Practice Committee. The adjudicative committees are the Registration Appeal Committee, the Hearing Committee and the Reinstatement Committee. The College strongly support having public representatives serve on all of its statutory committees and on its governing body. However, the requirement that one of the public representatives on each of these committees must also be a member of the Board is problematic for the following reasons:

1. Appointments are done through government often involve delays. Even when public representative positions are eventually filled by government, or immediately filled through the processes of the regulator, there are frequently issues of availability for the scheduled times of meetings or hearings. For adjudicative committees in particular, there is not an advance schedule of when hearings will occur, as they are entirely dependent on when the need for such hearings arise. Public representatives often have either other job commitments, vacation or family commitments, or other reasons why they cannot make themselves available within the reasonable time required for such committee meetings. Allegations of delay can lead to the potential overturning of committee decisions for lack of procedural fairness. When the public representatives on the governing body must sit on these committees, it can cause scheduling issues, and quorum issues. This is


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particularly problematic when the statutes establish timelines within which these adjudicative processes must take place. Flexibility is needed to allow for the appointment of public representatives from other than the limited pool sitting on the governing body, to fill these positions as needed.

2. It is not unusual for committee members to have conflicts of interest that can arise from personal knowledge of the member who is the subject of the committee meeting or hearing, or other circumstances giving rise to a potential conflict of interest. Again, with a prescribed requirement that the public representative must be a member of the governing body, there is a very limited pool of individuals to select to populate committees. This becomes particularly difficult when it is recognized in the context of the need for independent adjudicators and adherence to rules of procedural fairness. A public representative who serves on the Investigation Committee (an initial decision-making body that has assessed the complaint) cannot serve on the Hearing Committee which adjudicates the very complaint investigated by the Investigation Committee. This further depletes the pool and leaves limited options when conflicts exist. 3. Finally, and perhaps most pointedly, with respect to the adjudicative committees, the parties before such adjudicative committees are the member who is the subject of the adjudication and the College itself. The Board is the embodiment of the College, and to require the public representative on the Board to serve on the adjudicative committee can give rise to a reasonable apprehension of bias. The Board makes many of the policy decisions that impact the manner in which committee meetings are conducted. The Board sets the overall policy objectives for the organization, consistent with the Act, which are then applied by committees of the College. For purposes of adjudicative committees, the College and the adjudicative committees must be seen to be at arms’ length and independent of each other, given that the College is one of two parties appearing before such committees.

While the College is not aware of any particular cases where this issue has been directly raised, this may likely be because many of the self-governing professions currently populate their adjudicative committees without members of the governing bodies serving on such committees. There are regulators who follow such practices for procedural fairness purposes such as the College of Physicians and Surgeons of Nova Scotia, and the Nova Scotia Barristers’ Society. Instead, these self-governing professions still gain the advantage of having public representatives serve on these adjudicative committees by populating them with public representatives who are not members of the governing body, who bring the same advantages as all public representatives without the concerns of such public representatives being aligned with one of the parties appearing before the adjudicative committee. Further, it is the College’s view that the requirement of the Self-Regulation Policy that stipulates that public representative members of the governing body must populate the regulatory committees of the profession, is contrary to the other Policy requirement that:

“The legislation creates registration, complaint investigation and disciplinary procedures in compliance with principles of fundamental justice and the Canadian Charter of Rights and Freedoms”.

The use of the term “procedures” must be read broadly enough to include procedures that lead to the composition of the adjudicative committees. For the reasons explained above, it is not possible to meet the principles of fundamental justice if certain members of the governing body


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are required to also sit on adjudicative committees, particularly in light of the reasonable apprehension of bias issues discussed above where the College is one of the parties in these adjudicative processes. Finally, it is interesting to note that in the recent Cayton report, referenced at footnote 1, it is recommended that Board members not be appointed to adjudicative committees, for some of the very reasons outlined above. For these reasons, the College requests that the Executive Council waive the requirement that the new Act stipulate that at least one public representatives of the Board also be required to serve on each statutory committee responsible for reviewing registration decisions or investigating or disciplining registrants.


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3.0 SCOPE OF PRACTICE

A. Revised Definition: “Practice of Paramedicine” The present definition of the "practice of paramedicine" does not provide a meaningful description of the profession. It presently states that the "’practice of paramedicine’ means the practices and procedures usually performed by a paramedic under the direct or indirect supervision of a medical practitioner”. In addition to the vagueness of this definition, the requirement for direct or indirect supervision of a medical practitioner has presented considerable problems in practice. In brief, paramedics, like other regulated health professionals, practice autonomously when matters are within their individual scope of practice, and practise collaboratively when advice or direction from others is appropriate. Paramedics are prepared through their education to make independent decisions when appropriate and are accountable through their standards of practice to collaborate when needed. A standard requirement to practice under the direct or indirect supervision of a medical practitioner:

• does not reflect the current realities of practice;

• is not practical;

• fails to take into account the different practice settings of paramedics; and

• is not consistent with the regulation of paramedics in other regulated jurisdictions in Canada.

The requirement for a paramedic to have direct or indirect supervision of their practice prevents:

o an otherwise qualified paramedic from practicing paramedicine because there is not a list of physicians willing to offer this service. This requires additional work by employers and the College to manage.

o the College from providing a labour mobility applicant from another jurisdiction with a substantially equivalent license when they use Chapter 7 of the CFTA to license in Nova Scotia if there is no physician available to provide supervision.

o Paramedics who wish to volunteer and/or charge fees to provide paramedical services at public events unless there is a supervising physician.

Situations that exemplify why the College believes the requirement for direct or indirect supervision of a paramedics practice by a physician is not necessary and the impact this requirement places on the delivery of paramedic services to the citizens of Nova Scotia are detailed below. Supervision First, recognizing that the vast majority of the paramedics licensed with the College practice in the pre-hospital setting, there is a concern in relation to an understanding of the paramedics’ practice environment. While physicians have the medical knowledge and expertise to collaboratively support the clinical decision making of a paramedic, most, if not all physicians, have not been required to obtain the specialized knowledge and skills a paramedic requires to work in this type of environment.


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Next, a paramedic is trained and educated in the knowledge, skills and judgement to primarily provide direct patient care in the out-of-hospital environment. The prehospital environment makes it almost, if not impossible for anyone to provide direct supervision to their practice. In the ground ambulance system of today, when a paramedic is attending to a patient, they generally collaborate with the paramedic with whom they are partnered. Paramedics also have access to collaboration from fellow paramedics, at the clinical support desk, via radio communications and/or a physician, who is also accessible via radio communication, but only when required. This occurs when the attending paramedic has determined there is a need to collaborate with another paramedic or a physician; otherwise the paramedic provides care under the clinical practice guidelines associated with the organization who employees them. Generally, a self-regulated health care provider is accountable to their employers for employment related issues and in the case of registration and licensure, as well as professional conduct, the College. The requirement for direct or indirect supervision of a paramedic’s practice clouds who the paramedic is ultimately responsible to and ultimately adds in another layer of regulation. Presently, all paramedics regardless of whether they are involved in research, administrative, educational, consultative, governance roles, etc., require physician supervision. This creates a number of additional concerns around subject matter expertise. In most cases the paramedics who are involved in these roles are more educated and knowledgeable about the practice requirements for these environments than that of the physician who may be supervising them. Not all physicians manage employees or students, so in situations where a paramedic is involved in education or management roles, it would seem inherently concerning if the paramedic was to be supervised by a physician who did not have this knowledge or expertise. A paramedic who has a doctorate in research and is working in a paramedical research environment would have research education and experience that far exceeds baseline research competencies taught in both undergraduate medical education and residency. Within the current ground ambulance system paramedics are required to have direct or indirect supervision of their practice by a physician who is employed by EHSNS. As one can appreciate, within today’s society paramedics are responding to a variety of patients, who would benefit from the paramedic consulting with a health care provider other than a physician. A good example of this situation was recently brought to light with the implementation of the Pallium Canada Learning Essential Approaches to Palliative Care (LEAP) program in the Nova Scotia ground ambulance system. Under this program, ground ambulance paramedics:

• were provided with additional information to support their current knowledge and expertise to manage this specific patient population in a manner that allows the patient to remain at home with family as opposed to being transported to a medical facility.

• have been delivering high-quality palliative care to patients in their homes via the EHS Special Patient Program2,3.

As this program has grown there have been occurrences when the EHSNS physician designated to provide supervision to the ground ambulance paramedic has not been specifically trained in palliative care resulting in advice from the EHSNS physician to the paramedic that is contrary to the principles the paramedic was taught during their information session on LEAP.


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In this particular situation, it would be more beneficial for the paramedics to collaborate with a Palliative Care Physician or Palliative Care Nurse. Paramedics also work within a number of Nova Scotia Health Authority Emergency Departments, including Cobequid Community Emergency Centre, Hants Community Hospital, Valley Regional, Soldiers Memorial, South Shore Regional, Dartmouth General, New Halifax Infirmary, Colchester East Hants Health Centre and Roseway. In these emergency departments paramedics work collaboratively with multiple health care providers, including nurses, respiratory therapists, medical radiation technologists, etc. as well as physicians. In these situations, it is generally the unit manager who is responsible for overseeing and managing the paramedics’ workload, as opposed to the physicians who are working in the department. Over the past two and a half years, the College has received a number of inquiries from paramedics and/or community groups who have enquired about the requirements for a paramedic to support local community sporting, recreational and public gathering events by providing paramedical services. However, the requirement for direct or indirect supervision of their practice and the lack of physicians willing to fulfil this requirement has precluded them from assisting their local communities.

In 2011 the Government of Nova Scotia implemented Collaborative Emergency Centre’s (CEC’s) utilizing nurses, paramedics and EHSNS physicians to provide the service. To accomplish this, the Government had to draw the heavily utilized paramedic and physician resources from the EHSNS infrastructure. Recognizing the limited number of physicians who are willing to commit to providing direct or indirect supervision to a paramedics practice, if the paramedic did not require the direct or indirect supervision of a physician, the Nova Scotia Health Authority would be in a position to hire a paramedic who would work collaboratively with nursing staff in the CEC and consult with a physician in a regional hospital about the requirements to manage a patient, then, if required engage the EHSNS system. A jurisdictional scan of all the Canadian provinces where paramedicine is currently self-regulated was conducted by McInnis Cooper and finalized on February 4, 2019, to determine whether other jurisdictions have a legislated requirement for medical supervision. New Brunswick, Alberta and Saskatchewan represent the jurisdictions where paramedic self-regulation currently exists; Manitoba is currently transitioning to self-regulation and has a Transitional Council in place assisting in that process. The information provided comes directly from the jurisdiction’s legislation or from staff within their respective organizations. The information we have gathered to date indicates that in jurisdictions were paramedic self-regulation exists there is no requirement for the direct or indirect supervision of a paramedics practice by a medical practitioner. For those jurisdictions where we were able to obtain a direct email response, we posed the following:

• Whether paramedics in “specific province” require supervision by a medical practitioner?

• If they do require supervision has that supervision been defined and/or described? The responses and their sources included:

• The Alberta College of Paramedics – “We are currently transitioning to the Health Professions Act. Under the HPA practitioners are responsible for their own practice and


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do not require a medical practitioner to supervise; however, they require a Quality Assurance (QA) and Quality Improvement Plan (QI) in place. We are currently working on implementation and I would be happy to share our processes as soon as they are approved as they are in draft form. Hope this helps.” Source – Judy Friesen – Associate Registrar, Standards & Evaluation.

• Emergency Services, Health Manitoba – “The transitional council has just finished a first cut on the delegated acts portion of the regulation for paramedics and they will not require supervision by a medical practitioner for the delegated acts under each licence classification.” Source – Corene Debreuil – Director of Emergency Services, Health Manitoba

• The Saskatchewan College of Paramedics – The initial question with the Saskatchewan College of Paramedics resulted in the following response, “No supervision required; some contact with medical control if performing specific activities/treating specific symptoms (i.e.: MFI, transfusion reaction, cardiogenic shock, etc…). In general, they can practice independently.” Source Jacqueline Messer-Lapage – Executive Director/Registrar. However, this resulted in a follow-up question from the College of Paramedics of Nova Scotia to the Saskatchewan College of Paramedics, which was, “Just one more question regarding the process in Saskatchewan…’In Saskatchewan, section 23 of The Paramedics Act limits the activities of the paramedic, emergency medical technician and emergency medical responder to those approved by the College of Physicians and Surgeons of Saskatchewan: [A paramedic] who provides an emergency treatment or administers a medication must do so in accordance with any protocols respecting the provision of emergency treatment or administration of medication by a paramedic, an emergency medical technician or an emergency medical responder that are approved by the College of Physicians and Surgeons of Saskatchewan.’ Is it still the case that the College of Physicians and Surgeons must approve the protocols in Saskatchewan?” The follow-up response from Mrs Messer-Lepage was, “yes, however changes to our legislation are in the queue to remove the requirement.”

For the one jurisdiction, New Brunswick, with whom we did not have direct communication we sourced information from their Act. Here we see that the Paramedic Association of New Brunswick regulates the practice within that jurisdiction. Section 2(1) of An Act Respecting the Paramedic Association of New Brunswick defines the practice of paramedicine as any professional service usually performed by a paramedic and includes the evaluation and treatment of persons in situations of illness and injury in accordance with the professional training and education of a paramedic, the management of emergency and non-emergency public safety and healthcare situations and the independent delivery of healthcare by a paramedic in mobile, community out of hospital or clinical settings, coordinated with physicians, nurses and other health professionals in accordance with the unique body of knowledge of paramedicine based on and partly shared with other health professions. This environmental scan of self-regulated paramedic jurisdictions appears to demonstrate that there is no requirement for the direct or indirect supervision of a paramedics practice within those jurisdictions; however, there seems to be a consistent theme in that there is a requirement for quality assurance and improvement processes.


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Based on the above, the environmental scan of self-regulated paramedic jurisdictions appears to demonstrate that there is no requirement for the direct or indirect supervision of a paramedic’s practice within those jurisdictions; however, there seems to be a consistent theme in that there is a requirement for quality assurance and improvement processes.

With respect to Quality Assurance/Improvement, we are proposing to include regulation making authority to permit the development of a QA program at a later date that could include QA initiatives by the College such as practice reviews. (see section 8 of this document).

In addition it must be noted that in Nova Scotia within the ground ambulance service there is already a robust QA system in effect for paramedics within the employ of EHSNS. The medical oversight provided by EHSNS provides for the delivery of relevant education to paramedics; the provision of written care protocols, procedures and policies; the availability of telecommunication where needed to enhance the delivery of care; and the use of a quality improvement system to evaluate the effectiveness of its services. Such QA systems by employers would presumably continue in effect, and are not designed to be impacted in any way by the removal of the legislated requirement for direct or indirect supervision.

Like other self-regulated professions where the registrants work within an employment setting, there are often dual systems of quality assurance programs that are in place. From a regulator’s perspective, these programs include requirements for certain hours in practice, completion of continuing competence requirements and other requirements developed by certain regulators such as randomized practice audits. Employers often maintain their own systems of “quality assurance” through individual performance reviews and other methods such as those currently in place at EHSNS. Our proposal allows those two systems to continue and to clarify that regulators and employers each have distinct yet complementary roles to play to ensure overall quality of care.

Based on all of the above, in order to provide a more clear description of the practice of paramedicine without the restrictions of requiring direct or indirect supervision, a revised definition is set out below. This proposed definition provides flexibility to enact regulations to add to the scope of practice as it evolves. It also clarifies that non-clinical roles like research, education, management and administration, etc. fall within the meaning of paramedicine. This creates the requirement that those engaged in such non-clinical aspects of practice must still be registrants with the College and meet College licensing requirements.

“Practice of Paramedicine”


2(za) "practice of paramedicine" means the practices and procedures usually performed by a paramedic under the direct or indirect supervision of a medical practitioner;

"Practice of paramedicine" means the application of specialized paramedic knowledge, skills and judgment to clients across the lifespan in accordance with approved standards of practice and clinical practice guidelines in order to: (a) assess, make a paramedic diagnosis, treat, and manage acute and chronic health conditions


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“Practice of Paramedicine”

in any setting including emergent, urgent, acute, and primary care; (b) promote health and injury prevention; (c) engage in such other services, roles, functions and activities as prescribed in the regulations and also includes relevant research, education, interprofessional collaboration, consultation, management, administration, advocacy, regulation or system development relevant to the above.

B. New Definition: “Expanded Scope of Practice”

It is intended that the Act be amended to include the concept of "expanded scope" to permit paramedics to expand their scope of practice as long as it still falls within the broad definition of the practice of paramedicine. Under the newly proclaimed Nursing Act, nurses with additional particular education can be approved by the governing Board to engage in activities or procedures that may fall outside the scope of practice of the particular licence they hold, but fall within the general scope of practice of the nursing profession. For example, the administration of vaccinations to children under five is outside the scope of practice of Licensed Practical Nurses. In remote areas where this service is needed, the Nursing Act allows for individually identified LPNs to complete additional education and training and be deemed competent to provide this service. That service falls within the broad scope of practice of the nursing profession as a whole (LPNs, RNs, and NPs), while remaining outside the scope of practice of nurses holding LPN licences. This concept has merit for the paramedic profession, where, for example, with the appropriate education a primary care paramedic (PCP) could administer antibiotics. There are two instances in which this would be beneficial and safe when treating members of the public.

o Sepsis is a leading cause of mortality with rates of 30-35%, exceeding that of stroke or heart attack. Like stroke and heart attack, sepsis is a time-dependent emergency with mortality rates increasing exponentially every hour a patient is delayed treatment with broad-spectrum antibiotics. While antibiotic administration is within Advanced Care Paramedic (ACP) scope, many rural sites (> than 1 hour from a health care facility) are staffed by PCPs. In the case of sepsis, it would be beneficial to allow for PCP administration of antibiotics; the benefits far outweighing the risks.

o Community Paramedic (CP) programs are being implemented more broadly across the province as well as nationally. Most CP skills are within PCP scope with the glaring exception of antibiotic administration. From a health human resources lens, utilizing ACPs exclusively in a CP capacity may not be the best strategy as their overall skill set is more beneficial for emergency response and advanced life support.


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The expanded scope of practice option could also be used in situations where the administration of paralytics is required. Similar to the above example, the administration of paralytics is within Critical Care Paramedic (CCP) scope of practice but not within that of ACPs. The following points are relevant in this regard:

o There are currently 25 licensed CCPs in the province, working exclusively in the tertiary care ED and the Air Medical Transport (LifeFlight) environment. Contrast this with over 400 ACPs practicing throughout the province on ground ambulance.

o Paralytics are most widely utilized in paramedicine for rapid sequence induction (RSI). RSI is required when airway control is needed but airway reflexes are still present, necessitating the need for paralytic administration.

o This can be a lifesaving intervention yet can only be performed by Emergency Medicine Physicians, Anaesthesiologists and CCPs. In certain instances, LifeFlight or adequately staffed emergency departments may not be available, especially, in rural areas. In such cases access to ACPs with expanded scope would be of benefit.

Based on the above, it is proposed that a new definition of “expanded scope of practice” be included in the Paramedics Act as set out below. This definition mirrors the definition of “expanded scope of practice” in the Nursing Act. In addition, a new section will need to be added to enable the Board to develop a process to approve expanded scopes of practice. Again, the language below mirrors that in the Nursing Act.

Proposed Concept for Definition of “Expanded Scope of Practice”

“expanded scope of practice” means those services not presently in the scope of practice of a particular class of licence, but within the scope of practice of the paramedicine profession, approved by the Board for practice by registrants who have completed education approved for that purpose by the Board Add new bylaw making authority: “respecting the approval procedure for expanded scopes of practice and for educational prerequisites for expanded scopes of practice;”

For all the reasons set out above, the changes to the definition of the scope of practice of paramedicine and the addition of authority to have expanded scopes is requested. A scope of practice statement is the foundation for a self-regulated profession. Scope of practice provides the basis for the development of practice standards, entry level competencies and paramedic curriculum content. For health care employers, scope of practice assists with staffing decisions and workforce planning. Most importantly, scope of practice defines the outer limits of permissible practice of paramedicine for both the profession and the public. However, paramedicine is a dynamic profession which is continually evolving. The definition of scope must allow for evolution and responsiveness to the health care needs of the population in


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a timely and efficient manner. Scope of practice should be sufficiently broad and flexible to permit innovation, growth and change. The proposed amendments, and the ability of the Board to approve “expanded scope of practice”, will more easily allow for continuing changes to the practice of paramedicine in the future. This will permit the College to address the changing needs of the public and eliminate barriers to optimize the scope of practice for individual paramedics.


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4.0 REGISTRATION AND LICENSURE

The current Act provides for a registration and licensure system in which registrants must qualify for initial registration in order to apply for licensure to practise. Registration is a one-time event and signifies that the registrant has met the qualifications for entry into the profession. In order to practise, registrants must also qualify for licensure. Licensure is an annual event and signifies that the registrant continues to meet the requirements of competence in order to practise. The proposed amendments will maintain this system of registration and licensure with important amendments to remove considerable operational challenges. A. Revised Committee names

In order to more accurately reflect the distinctions between the registration and licensing processes and the roles of the current committees involved in the registration and licensing processes, the following changes are proposed:

Revised Committee names


Registration Committee

Registration and Licensing Committee

Registration Appeal Committee

Registration and Licensing Review Committee

The term “appeal” as it relates to the registration and licensing process should be changed to “review” to better describe the type of process that is anticipated to be used, which is consistent with the Fair Registration Practices Act.

B. Revised and New Definitions

(i) The current Definitions Regulations under the Paramedics Act defines a

“paramedic program” as a diploma program recognized by Council. It is not known in the future if other types of programs may be developed for the different classes of licences for paramedics. The intent of the revised definition is to retain a diploma program as the required education for entry into either the primary care class or primary care – conditional class of licence. For other classes of licences the Board is able to define the specific education required for those classes. Where it is anticipated there may be new programming for other classes of licence in the future, it is important to have flexibility to adapt to additional programming, while at the same time ensuring there is no “credential creep” for entry as a primary care paramedic.


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Revised Definition: paramedic program

Current language Proposed Concept

“paramedic program” means a diploma paramedic program recognized by the Council under Section 35 of the Paramedic Regulations.

“paramedic education program” means for those applicants seeking a licence in one of the primary care classes, a diploma paramedic program approved by the Board, and for those applicants seeking a licence in other classes, such other programs as are approved by the Board.

(ii) While the Act currently allows for competence assessments, it is silent on how to

address gaps that are identified through those assessments. A new definition of a “bridging education program” should be added as the means by which such gaps will be addressed.

New Definition: bridging education program

“bridging education program” means “a program approved by the Registrar that addresses gaps in competencies identified through a competence assessment or through information otherwise provided to the College”.

(iii) In order to better describe the type of process that is anticipated to be used, and

to ensure consistency with the Fair Registration and Practices Act, the term “appeal” as it relates to the registration and licensing process shall be changed to “review”.

Revised Term: Appeal


Appeal

Review

C. Classes of licences

There is a desire to simplify and streamline the available categories and classes of licences for the College, which will be addressed likely in the new regulations to be developed once amendments to the Act have been passed. The current Regulations list four classes of licences:

a. Primary care; b. Intermediate care; c. Advanced care; and d. Critical care.


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There are four categories within each class of licence:

a. Practicing; b. Restricted practicing; c. Temporary; d. Restricted temporary.

In order to attempt to streamline classes and categories, it is recommended that any reference to categories be removed, and instead to have eight distinct classes. In essence, the four classes will mirror the four existing classes, but will be further divided so that each class has a separate class called “conditional" where terms, conditions or restrictions may be placed on the license. In other words, the eight classes will be as follows:

Proposed Concept - New classes of licences

a. Primary care paramedic; b. Primary care paramedic-conditional; c. Intermediate care paramedic; d. Intermediate care paramedic-conditional; e. Advanced care paramedic; f. Advanced care paramedic-conditional; g. Critical care paramedic; h. Critical care paramedic-conditional.

D. Waiver provision

Section 40(6) of the Paramedic Regulations contains a provision which grants the Registration Committee the authority to waive any of the criteria for registration, licensing or renewal if required by law or if “it is consistent with the objects and purpose of the College”. To ensure the broad availability of this waiver provision, it shall be included in the Act, rather than the regulations. Further, it should be available to all who make registration and licensing decisions – not just the Registration Committee. It should recognize that where criteria for registration or licensing are inconsistent with any law (such as labour mobility laws) there is no discretion about the application of the waiver. The proposed concept is as follows:

Waiver provision


The Registration Committee may waive any of the criteria for registration, licensing or renewal of a licence set out

(1) The Registrar, Registration and Licensing Committee, and Registration and Licensing Review Committee must waive any of the criteria for


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Waiver provision

in these regulations for either of the following reasons: (a) it is required by law; (b) it is consistent with the objects and purposes of the College.

registration or licensing for either of the following reasons: (a) The criteria conflicts with the requirements of

the Canadian Free Trade Agreement; (b) It is required by law.

(2) The Registrar, Registration and Licensing Committee, and Registration and Licensing Review Committee may waive any criteria for registration or licensing or renewal of a licence if the waiver is consistent with the objects and purpose of the College.

Similar language has recently been adopted in regulations under the Audiologists and Speech Language Pathologists Act in Nova Scotia.

E. Registration and Licensing process

The Act and regulations must be clear with respect to the respective roles of the Registrar, the

Registration and Licensing Committee and the Registration and Licensing Review Committee.

While there is no real change in the substance of the registration and licensing process that is

recommended, the language could benefit from being more explicit in this regard.

The relevant sections of the Act and Regulations should clearly provide for a process enabling

the Registrar to make decisions on registration and licensing if all of the criteria have been met.

If the Registrar is uncertain or believes that one or more of the criteria have not been met, then

the matter should be referred to the Registration and Licensing Committee for decision. If an

applicant is dissatisfied with the decision of the Registration and Licensing Committee, the matter

can then be referred to the Registration and Licensing Review Committee. This process will be

consistent with the requirements of the Fair Registration Practices Act.

Language for this type of process can be borrowed from the recently proclaimed Nursing Act,

which adopts this type of clear decision-making process.

In addition, the current regulations (section 9) require that a paramedic member of Council serve

on the Registration Appeal Committee. In Section 3 (E) earlier in this document, rationale was

provided for why public representative members of Council should not serve on adjudicative

committees of the College. The same reasoning applies to paramedic members of Council

serving on the Registration Appeal Committee, which performs an adjudicative function. The

reasons won’t be repeated here, but based on those reasons the College requests removal of

this requirement in the amendments being sought.


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F. Absence of a licence

Section 13 of the Paramedic Regulations currently notes that a person who previously practiced in any jurisdiction who has not held a license to practice for two years or longer must meet certain criteria and may be required to meet other criteria. There is some uncertainty whether the phrase “any jurisdiction” referred to just Nova Scotia, or any jurisdiction. There is also uncertainty respecting whether a competence assessment and bridging education program, if necessary, should be mandatory or discretionary, for such individuals. Questions of current competence do arise when someone has not held a licence for 2 years or longer. Technologies/procedures change, and it is imperative that the paramedic be up to date. The requirement for a competence assessment is consistent with the overarching purpose of public protection. The definition of a competence assessment is so broad in any event that it could encompass everything from an interview with the Registrar to the taking of education programs, depending on the circumstances of the individual. Because there is flexibility in determining what is involved in an individual’s competence assessment, it is prudent to build in this requirement. The proposed concept is as follows:

Absence of a licence


13 A person who previously practised paramedicine in any jurisdiction who has not held a licence to practise for 2 years or longer, other than a person whose licence has been revoked, must do the following: (a) notify the Registrar in writing of their intention to return to practice; (b) if currently or previously registered in another jurisdiction, provide the Registrar with a certificate of standing from each jurisdiction where the applicant practised to prove that there are no outstanding complaints, prohibitions, conditions or restrictions against the member practising paramedicine in the Province; (c) if the Registrar determines it is necessary, successfully complete a competence assessment in the form determined by the Registrar;

Where a person has not held a licence to practice in Nova Scotia or any other jurisdiction for two years or longer, then before returning to practice a person must: (a) notify the Registrar in writing of their intention to return to practice; and (b) successfully complete a competence assessment and bridging education as determined by the Registration and Licensing Committee.


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Absence of a licence

(d) if the Registration Committee determines it is necessary, successfully complete any paramedic refresher program, paramedic program or evaluation specified by the Registration Committee.

G. Registration Criteria

Many of the criteria currently listed in the Paramedic Regulations as criteria for entry in rosters should become criteria for initial entry in the Registrar as they reflect first step qualifications to become registrants. The proposed new criteria for initial entry in the Registrar are as follows:

Proposed Concept - Registration criteria

1. The applicant completes the form approved by the Registrar and pays fees determined

by the Board; 2. The applicant indicates type of licence being sought; 3. The applicant satisfies one of the following:

a. The applicant is a graduate of an approved paramedic education program for the class of licence sought, (clarify that if a first time registrant anywhere, the application must be received within 2 years of completing the program, or the person will be required to complete a competence assessment and any bridging education arising from that) (This is a change from the 1 year period currently referenced in section 17(5) of the Regulations);

b. The applicant is a graduate of an education program, other than a “paramedic education program” that in the opinion of the Registration and Licensing Committee is deemed equivalent to an approved paramedic education program for the class of licence sought;

c. The applicant has graduated from an education program deemed relevant by the Registration and Licensing Committee to the practice of paramedicine for the class of licence sought, other than a program set out in (a) and (b), and has completed a competence assessment directed by the Committee and such bridging education arising from the competence assessment as required by that committee.

4. The applicant has successfully completed any examinations that may be required by the Board;

5. If currently or previously registered or licensed in another Canadian jurisdiction as a paramedic or any other regulated professional, applicant must a provide certificate of standing satisfactory to the Registrar from any current jurisdiction where licensed or if not currently licensed, the last jurisdiction(s) where licensed;

6. If currently or previously registered or licensed as a paramedic or any other regulated professional in a jurisdiction outside of Canada, applicant must provide a certificate of standing from each such jurisdiction in which the applicant was registered, to the satisfaction of the Registrar;


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7. The applicant has provided proof in such manner as directed by the Registrar that the applicant has the character, competence and capacity to safely and ethically practice;

8. The applicant is a Canadian citizen or legally entitled to live and work in Canada; 9. The applicant has demonstrated proficiency in the English language in the manner

prescribed by the Registrar; and 10. The applicant is not prohibited from practicing paramedicine through the decision of

any adjudicating body or through voluntary agreement or otherwise.

H. Class of licensure criteria

Some lack of clarity exists respecting the specific criteria for the issuing of any licence. With the reduction in types of licences that is proposed, there will be general criteria for the holding of any class of licence, and then some specific provisions for certain classes. The following are the proposed concepts for any class of licence:

Proposed Concept - Class of licensure criteria

1. The applicant must be registered on the Register; 2. The paramedic education program completed as a registration criterion must be for the

class of licence sought by the applicant; 3. The applicant must complete the approved form approved by the Registrar and pay

the fee approved by the Board; 4. The applicant must comply with the absence from practice section; 5. The applicant must meet the professional liability insurance requirements set by the

Board; 6. The applicant must complete such examinations as may be required by the Board; * 7. The applicant must have the character, competence and capacity to safely and

ethically practice; * 8. The applicant must meet the continuing competence requirements set by the Board; * 9. The applicant must meet the practice hour requirements set by the Board. *

*Items marked with an asterisk will distinguish between applicants for a first-time licence, and those seeking renewal of a licence. For example, there would be no practice hour requirements for a new graduate seeking his or her first licence, but there would be practice hour requirements for those registrants who are seeking to renew their licence on an annual basis. Further, to recognize that a person may become registered and then choose not to be licensed for a considerable period of time, it is also recommended to add a section to indicate that if the application is for the first entry in a class of licence, and the application has not been approved within 2 years of registration, the applicant must successfully complete a competence assessment and bridging education as determined by the Registrar. In addition to the criteria for any class of licence the following must also be addressed as the proposed criteria for the class of licences identified below:


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Emergency Health Service Nova Scotia (EHSNS) had regulated the practice of paramedicine in Nova Scotia for over two decades, before the College assumed this role on April 1, 2017. From what the College understands, when all the private ambulance operations were merged into one unified system, EHSNS required that there be certain number of advanced life support providers working within the EHSNS system at any given time. However, there was a shortage of Advanced Care Paramedics to fulfil that role. It is believed that EHSNS recognized the National Occupational Competence Profile for Paramedicine (2001) as developed by the Paramedic Association of Canada which detailed four types of pre-hospital care providers including Medical First Responder, Primary Care Paramedics, Advanced Care Paramedics and Critical Care Paramedics, the latter two being identified as advanced life support providers. However, due to the time constraints associated with training an Advanced Care Paramedic and that most staff were Primary Care Paramedics the province chose to implement the Intermediate Care Paramedic class of licensure. This allowed the government to provide its own internal advanced life support training to those paramedics who were already employed within the EHSNS system to meet the systems demands. In April 2002 Emergency Health Services Nova Scotia’s revised their policy regarding paramedic regulation to indicate that “EHS will no longer register ICP’s. Currently registered ICPs may re-register as required.” The College believes this occurred because paramedics who were within the EHSNS system began attending and completing Advanced Care Paramedic programming and the ICP class of licensure was no longer required. Presently, the membership by class of licensure is:

• PCP – 56% (706/1264)

• ICP – 6% (76/1264)

• ACP – 36% (458/1264)

• CCP – 2% (24/1264) Nationally, only three other jurisdictions had been registering and licensing ICP’s: Saskatchewan, Manitoba and Prince Edward Island. From discussions with the Canadian Organization of Paramedic Regulators, where these three provinces are represented, they no longer register new ICP’s, but do permit those who are registered as ICP’s to renew their licences. Finally, training programs for intermediate care paramedics has not existed within Canada for almost two decades, which means since that time paramedics are unable to obtain the training required for this class of licensure. As a result, the proposed concepts are as follows:

Proposed Concept - Intermediate care paramedic

There will be no additions to the intermediate care paramedic (ICP) class for those who do not already hold the qualifications for this class at the time the regulations are passed, unless they are transferring an intermediate care paramedic (ICP) licence from another jurisdiction in Canada under the Canada Free Trade Agreement.


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Proposed Concept - Conditional class

With respect to licences in a conditional class, the following criteria are proposed:

A Registrant’s name may be entered in the conditional roster of any class if:

i. The applicant and the Registrar agree to issue a licence that is subject to any conditions or restrictions;

ii. Any Regulatory Committee of the College imposes conditions or restrictions.

The intent of this change is to establish that the Registrar cannot unilaterally impose conditions or restrictions on an individual – the Registrar can only “impose” conditions when agreed upon by the applicant. Otherwise, it is only a regulatory committee that can impose such conditions.

It is proposed subject to the restrictions around the intermediate care paramedic (ICP) class noted above, the holder of a licence may change from one class to another where they:

a. Complete the form approved by the Registrar and pay the fee approved by the board;

b. Establish they have completed the education requirements for the class of licence sought. This section will reference the 3 methods by which the education program is deemed acceptable by mirroring the language set out above for the Registration criteria;

c. Establish they have completed the examinations approved by the board for that class of licence; and

d. Meet all other criteria for the new class of licence.

To avoid the confusion that can arise from the holding of more than one class of licence, it is recommended that the legislation specifically preclude that possibility by stating that a paramedic may not hold more than one class of licence at a time.


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5.0 PROFESSIONAL CONDUCT

A. Revised Definitions

Terms used in the professional conduct process, such as “professional misconduct”, “incompetence”, “conduct unbecoming” and “incapacity” shall be updated to reflect language used in legislation like the Nursing Act or the Medical Act. Consistency among legislation was one of the guiding principles for the College. Other professions generally provide more examples of what is meant by “professional misconduct”. Apart from adding these examples, the proposed amendments below are designed to mirror language in other self-regulated professions. The Nursing Act has been used as the template.

Professional conduct definitions


2(zb) "professional misconduct" includes such conduct or acts in the practice of paramedicine that, having regard to all the circumstances, would reasonably be regarded as disgraceful, dishonourable or unprofessional and, without limiting the generality of the foregoing, may include breaches of

(i) the code of ethics approved by the Council, (ii) the accepted standards of the practice of paramedicine, and (iii) this Act, the regulations or policies approved by the Council.

"professional misconduct" includes such conduct or acts relevant to the practice of the profession that, having regard to all the circumstances, would reasonably be regarded as disgraceful, dishonourable or unprofessional, including (a) failing to maintain the standards of practice; (b) failing to adhere to any codes of ethics adopted by the College; (c) abusing a person verbally, physically, emotionally or sexually; (d) misappropriating personal property, drugs or other property belonging to a client or an employer; (e) inappropriately influencing a client to make or change a legal document; (f) abandoning a client; (g) neglecting to provide care to a client; (h) failing to exercise appropriate discretion with respect to the disclosure of confidential information; (j) falsifying records; (k) inappropriately using licensing status for personal gain;


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Professional conduct definitions

(l) promoting for personal gain any drug, device, treatment, procedure, product or service that is unnecessary, ineffective or unsafe; (m) publishing, or causing to be published, any advertisement that is false, fraudulent, deceptive or misleading; (n) engaging or assisting in fraud, misrepresentation, deception or concealment of a material fact when applying for or securing registration or a licence to practise or taking any examination provided for in this Act, including using fraudulently procured credentials; and (o) taking or using a designation or a derivation or abbreviation thereof or describing the person's activities as "paramedicine" in any advertisement or publication, including business cards, websites or signage, unless the referenced activity falls within the practice of paramedicine.

2(f) "conduct unbecoming the profession" means conduct in a member's personal or private capacity that tends to bring discredit upon the practice of paramedicine.

"conduct unbecoming the profession" means conduct in a registrant's personal or private capacity that tends to bring discredit upon registrants or the practice of paramedicine.

2(o) "incompetence", in relation to a respondent, means the display of a lack of knowledge, skill or judgement in the respondent's practice of paramedicine that, having regard to all the circumstances, rendered it unsafe for the respondent to practise at the time or renders it unsafe for the respondent to continue in practise without remedial assistance.

"incompetence", in relation to a registrant, means a lack of competence demonstrated in the registrant's care of a client or in the practice of paramedicine that, having regard to all the circumstances, rendered the respondent unsafe to practise at the time or that renders the respondent unsafe to continue in practice without remedial assistance.

2(n) "incapacity" means a medical, physical, mental or emotional condition, disorder or addiction that renders or rendered a member unable to practise with competence or that may endanger or has endangered the health or safety of individuals.

"incapacity" means the status whereby a registrant has or had a medical, physical, mental or emotional condition, disorder or addiction that renders or rendered the registrant unable to practise with competence or that endangers or may have endangered the health or safety of clients.


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B. Investigations and Hearings

Throughout the sections of the current Act and regulations that address investigations and hearings, references are made to actions being taken by full committees. Most other statutes of regulated professions allow for the appointment of panels of these committees to conduct their regulatory functions, so fewer people can be involved, while at the same time ensuring appropriate representation from registrants and public members. There are some clear errors in the current Act respecting the investigative process that require correction. For example, the current section 51 states that “Without receipt of a written complaint, an investigation committee may” ….do various things. There is no corresponding authority for matters that are the subject of a written complaint. This error was imported from other legislation and appears to have been cut and pasted into the current Paramedics Act. Several of the other health professions statutes have been amended in recent years in a way that allows for a consistent approach to investigations and hearings. These statutes incorporate provisions that are flexible, enabling, and fair to the complainants and members, and offer appropriate transparency to the public. Where the Nursing Act has been recently proclaimed in effect, its entire section on investigations and hearings should be incorporated into the Paramedics Act. This promotes consistency among practices and avoids reinventing the wheel.

Investigations and Hearings


Found at sections 37-84 of the current Act and at sections 54-58 and 64-89 of the current Paramedic Regulations.

Incorporate language from sections 55-108 of the Nursing Act into the new Paramedics Act.


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6.0 FITNESS TO PRACTISE

The College’s fitness to practise process is currently set out in the regulations. As above, there are some improvements to the process that have been introduced into legislation such as the Nursing Act that would benefit this College. Rather than re-inventing processes, it is recommended that the newly revised fitness to practice process set out in the recently proclaimed Nursing Act be incorporated into the new Paramedics Act.

Fitness-to-Practise


Found at sections 59-63 of the current Paramedic Regulations.

Incorporate language from sections 116-129 of the Nursing Act into the new Paramedics Act.


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7.0 QUALITY ASSURANCE INITIATIVES

The current Act creates regulation making authority “providing for the audit of a member’s practice”. There is some uncertainty about the scope of this regulation making authority. To allow for the development at a later time of a Quality Assurance Program, that may include components like practice reviews, there should be flexible regulation making language that permits the development of regulations. The proposed concept is as follows:

Quality Assurance Program


21(2) Subject to the approval of the Governor in Council, the Council may make regulations … (zb) providing for the audit of a member's practice.

Subject to the approval of the Governor in Council, the Council may make regulations respecting the development and implementation of a Quality Assurance Program, and its enforcement.


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8.0 PROTECTED TITLES AND PRACTICE

While sections 34-36 of the current Paramedics Act provide some important provisions respecting title protection, there are other general aspects respecting the practice of paramedicine that should also be clearly referenced. For example, the concept that a paramedic must only practice within his or her individual scope of practice is not clearly captured in the current Act or regulations. Instead, the regulations simply indicate that once issued a certain class of licence, the member “may” practise within their individual scope. The newly proclaimed Nursing Act contains many provisions in its “Practice” section that could be readily imported into paramedic’s legislation. It is recommended that sections 45-54 of the Nursing Act be generally included, adapted as needed for the paramedic’s profession. Examples of the matters covered under those sections include:

• A requirement for each registrant to comply with the Act, regulations, bylaws, code of ethics and standards of practice;

• A duty to cooperate with the College and its Registrar and Committees;

• A duty to maintain current contact information;

• A duty to maintain a record of practice hours;

• A duty to practise only within the registrant’s individual scope of practice;

• A duty to report to the Registrar if there are reasonable grounds to believe another registrant has engaged in professional misconduct, incompetence or conduct unbecoming the profession, or is incapacitated or presents a risk to the public;

• Authority for persons seeking to practice for limited times or purposes to have a simplified process to do so;

• Authority respecting the jurisdictional authority for electronic practice;


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9.0 CUSTODIANS

The current Act is silent respecting any authority to appoint a custodian of health records. In other health professions where registrants have the ability to engage in independent practice, provisions are made for the College to access court orders to appoint custodians if there is any risk to the protection of the records. While the concept of independent practice for paramedics is in its early stages, it will be helpful to have enabling language to allow for the appointment of custodians in the future. It is recommended that the new Act include a regulation making provision permitting the College to develop regulations at a later time respecting the appointment of custodians:

Proposed Concept - Custodians

(2) Subject to the approval of the Governor in Council, the Board may make regulations respecting the appointment of custodians.

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