Article

Nurse Leaders’ Experiences of Implementing Regulatory Changes in Sexual Health Nursing Practice in British Columbia, Canada

Policy, Politics, & Nursing Practice 14(2) 69–78 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1527154413510564 ppn.sagepub.com

Vicky Bungay, PhD, RN1 and Janine Stevenson, MSN, RN2

Abstract Most research about regulatory policy change concerning expanded nursing activities has emphasized advanced practice roles and acute care settings. This study is a contribution to the small pool of research concerned with regulatory policy implementation for nurses undertaking expanded nursing practice activities in a public health context. Using the regulatory changes in certified nursing practice in one Canadian province as our starting point, we investigated the experiences of nurse leaders in implementing this change. Using a qualitative interpretive descriptive approach informed by tenets of complexity theory, we examined the experiences of 16 nurse leaders as situated within the larger public health care system in which nurses practice. Two interrelated themes, (a) preparing for certification and (b) the certification process, were identified to illustrate how competing and contrasting demands between health care and regulatory organizations created substantial barriers to policy change. Implications for health service delivery and future research are discussed. Keywords nursing leadership, regulatory frameworks, scope of practice, health care system, self-regulation, sexually transmitted infections, systems theory

Regulation of nursing as a health profession serves as a policy instrument that aims to protect the public from unsafe and unqualified health care providers (Aldridge, 2008; Flook, 2003). Regulatory policies achieve public protection by establishing and enforcing nursing’s professional practice and education standards (Aldridge, 2008; Wearing & Nickerson, 2010). Over the past century, there have been substantial revisions within regulatory policies governing nursing practice throughout the world (International Council of Nurses, 2009). What began in many countries in the early 1900s as a registry process has evolved into a complex series of policies and frameworks that outline the processes (e.g., education, fitness to practice) by which individuals are granted the right to perform certain activities within their professional scope of practice (Flook, 2003). The evolution of nursing regulations has been tumultuous. Many regulatory policies have failed to adequately represent the full scope of nursing practice that occurs in the clinical setting (McIntyre & McDonald, 2010). Furthermore, as

regulatory policies have evolved to better reflect nursing practice, nurses continue to face organizational barriers to policy implementation, including inadequate funding, limited leadership support, and demanding workloads that interfere with their ability to undertake their work (D’Amour et al., 2012; Di Censo et al., 2010; Underwood et al., 2009). To date, much of the extant research associated with nursing regulations has emphasized the need for the regulatory policies to reflect real-time nursing practice (e.g., Wearing & Nickerson, 2010) or barriers to nurses working to the full scope of their regulated practice, especially in advanced practice roles such as nurse 1 2

University of British Columbia, Vancouver, BC, Canada BC Centre for Disease Control, Vancouver, BC, Canada

Corresponding Author: Vicky Bungay, PhD, RN, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC V6T2B5, Canada. Email: [email protected]

70 practitioners (e.g., Di Censo et al., 2010; Kaasalainen et al., 2010). Less attention has been given to the regulatory policy changes governing expanded nursing practice activities beyond the regular scope of practice that do not require graduate education. Additionally, there is a veritable dearth of information regarding the process of implementing professional regulatory changes in clinical settings and the impact of these changes for the coordination and administration of health service delivery. The more general policy research that has occurred (e.g., Heward, Hutchins, & Keleher, 2007), however, has illustrated the need for evidence-informed policy implementation strategies that take into consideration organizational processes and culture, leadership capacities, and the perspectives of the individual nurses whose practice will be affected as a result of the new policies. In this article, we present our findings from a recent qualitative study that examined nurse leaders’ experiences of implementing provincial regulatory policy changes affecting nursing practice in sexual health care in British Columbia, Canada. To situate our work, we begin with an overview of the provincial context in which these changes occurred.

The British Columbia Context Within the province of British Columbia, there have been substantial changes within the regulatory frameworks governing nursing practice. In 2005, The Registered Nurses’ Act was suspended and the Nurses (Registered) and Nurse Practitioner Regulation came into effect under the revised Health Professions Act (HPA; Wearing & Nickerson, 2010). These changes also afforded the College of Registered Nurses of British Columbia (CRNBC) authority to independently regulate the practice of registered nurses (CRNBC, 2012a). The nursing community, including the CRNBC, identified several concerns within the new regulatory frameworks, including a disconnect between what was occurring in the clinical practice settings and the activities included within the new scope of practice regulations. More specifically, health policy advisors reported that some practice activities being regularly carried out were not addressed in the HPA and that a large discrepancy existed in the educational preparation of nurses across the province performing these activities (CRNBC, 2010) . One area of concern was the nursing practice of independently diagnosing and treating sexually transmitted infections (STIs). Recent research illustrated that more than 600 public health nurses in British Columbia were involved in some aspect of STI diagnosis and treatment, and substantial inconsistencies existed in the educational preparation of nurses carrying out these activities (Bungay, 2010). Additionally, these practices were carried out under a diverse array of authorizing

Policy, Politics, & Nursing Practice 14(2) mechanisms, for instance, standing orders, delegated medical function, and indirect orders (Wearing & Nickerson, 2010). In many settings, physicians delegated the activity but were seldom involved in ensuring the nurse was competent, a necessary condition for delegation (CRNBC, 2010). There was also substantial confusion regarding ultimate responsibility for the patient care decisions (Wearing & Nickerson, 2010). Given the CRNBC mandate to protect the public and the lack of clarity within the existing regulatory policies governing STI care and nursing practice, the CRNBC developed a new regulatory framework for nurses working in expanded practice activities in the independent diagnosis and treatment of STIs (Wearing & Nickerson, 2010). Within this new regulatory framework, the expanded activities were identified as certified practices and the conditions and qualifications for practice of these activities were articulated. The regulated certified nursing practice activities were detailed in evidence-based protocols termed Decision Support Tools that were publically available via the CRNBC (CRNBC, 2010). Nurses received certification and the right to undertake these expanded activities if they successfully completed a CRNBC-approved educational program and were listed within the registry of certified nurses (Wearing & Nickerson, 2010). The new regulations took effect April 2010. Public health nurse leaders with responsibilities in the coordination and delivery of sexual health nursing services were charged with ensuring that these regulations were upheld and that the standards of nursing care were met (Stevenson, 2012). We recognized that while research was underway to examine the scope of frontline nursing practice activities in sexual health care, there was a substantial need to understand the policy implementation processes at an organizational level. We were specifically interested in the experiences of those with the responsibility for implementing the change. Nurse leaders held responsibility for implementing the changes within their roles of coordinating and managing sexual health service delivery and supporting professional nursing practice. We proposed that by investigating the experiences of nurse leaders, we could learn how the policy implementation process occurred and identify the organizational and structural barriers and supports to policy implementation. We also sought to address some of the current knowledge gaps regarding the role of nursing leadership in policy implementation.

Methods The research protocol received ethical approval from the University of British Columbia and participating health authority behavioral research ethics boards, and data collection and analysis occurred in 2011–2012.

Bungay and Stevenson Data collection included individual and group interviews with 16 nurse leaders from three regional health authorities. The health authorities represented the urban and rural geographic differences in which sexual health nurses practice and the differing client populations situated within these locales. We used a purposeful sampling strategy (Thorne, 2008). We drew on our knowledge and experience from working with nurse leaders to compile a list of potential participants within each health authority who had, as part of their responsibilities, the coordination and management of public health nursing sexual health services (e.g., prevention and management of STIs) and would be responsible for implementing the regulatory changes. We shared the lists with health authority representatives to assess for accuracy and completeness. One nurse educator and two nursing practice leaders were added to our list because of their assigned responsibilities in implementing regulatory changes. We contacted potential participants via email or phone to share information about the study and to invite them to participate. Nurse leaders were offered the opportunity to participate in group or individual interviews. The format option facilitated the timing and ease of participants’ scheduling for interviews and provided individuals the opportunity for the most comfortable format for sharing their perspectives. The interviews were conversationally oriented and explored the leaders’ experiences of implementing certified practice regulations as well as their perspectives regarding the significance of the regulatory change for health service delivery. Interviews lasted 30 to 60 min, were digitally recorded, and transcribed verbatim. We checked transcripts for accuracy and completeness. Four group interviews (with two or three participants per group) and five one-on-one interviews were conducted.

Data Analysis Analysis began early in the data collection process and continued throughout the project in an iterative manner using an interpretive thematic approach (Thorne, 2008). As data were continually gathered, we read interviews repeatedly to identify any recurring patterns or differences (Carspecken, 1996). Data were reread for linkages to theory and to highlight illustrative examples that depicted patterns and differences for exploration in future interviews. We constructed initial codes that were thematic descriptions of leaders’ perspectives and experiences in the implementation of certified nursing practice regulations that attended to the variation and similarities within and between their experiences. As the analysis progressed, we refined codes to reflect a more theoretical approach to illustrate how the implementation of regulatory changes influenced, and were

71 influenced by, other factors within public health service delivery, including nurse leaders’ autonomy in implementing the changes and competing public health system demands. To guide our analysis, we drew from tenets of complexity theory and implementation science (Edwards, Rowan, Marck, & Grinspun, 2011; Rickles, Hawe, & Shiell, 2007). Complexity theory supports that the health care system is a complex adaptive system made up of interconnected entities that change and evolve (Miller, Crabtree, McDaniel, & Strange, 1998; Wilson, 2009). The interconnected nature of complex adaptive systems guided analysis to help us to understand how and why changes such as new regulatory frameworks were influenced by and influenced other system changes (Miller et al., 1998; Ploeg, Davies, Edwards, Gifford, & Miller, 2007). Specifically, we drew on these tenets to identify public health nursing as a complex adaptive organizational system and postulated that this system comprised many interacting subsystems (e.g., public health policies, models of health service delivery) including the individual actions of people within these systems (e.g., public health nurse leaders, College of Registered Nurses, Medical Health Officers). We recognized that a change in regulatory policies informing nursing practice did not occur in a vacuum decontextualized from the public health care context in which the nurses practiced. By examining the experiences of nurse leaders within the realm of complex adaptive systems, we were able to examine how they experienced the implementation of regulatory changes, highlighting individual and structural strengths and limitations with regard to their capacities to implement and support these changes. Additionally, in keeping with the interpretive descriptive approach (Thorne, 2008), our aim was not to capture all possibilities in variation but to continue to build on the knowledge concerned with regulatory frameworks for nursing practice that can serve to inform future interventions and research in the field.

Results The 16 nurse leader participants held a diversity of titles and responsibilities in the coordination and delivery of nursing care: clinical nurse leader (n ¼ 2), program manager (n ¼ 10), practice development leader (n ¼ 2), nurse educator (n ¼ 1), and operations director (i.e., senior manager for several program managers; n ¼ 1). The leaders were from an array of sexual health programs that provided services to urban and rural populations in outreach, primary care, public health, and specialized sexual health clinical settings. Most of the leaders managed or provided professional practice support in multiple settings within a specific geographic region (referred to as a health service delivery area) in their respective health

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authority, while others were responsible for a specialized sexual health program in one clinical setting. Many of the programs offered collaborative models of health care that included certified nurses, nurse practitioners, and physicians, while others were nurse led with physicians and nurse practitioners available for consultation in person or by phone. The number of staff reporting to the nurse leaders varied from 20 to 200, illustrating the diversity in organizational structures between and within the health authorities. All the participants strongly believed that certified practice regulation was a tremendous professional boost for nursing because it enabled public and legal recognition of nursing’s autonomy in sexual health care while also establishing a normative, evidence-based standard for sexual health nursing practice throughout the province. Implementing certified practice regulation, however, was described as a series of resource-intensive processes that intersected with other organizational policies and processes within their respective health authorities, the CRNBC, and the educational institutions that provided certified practice education. In analyzing their experiences as a system-level change occurring within a nexus of interconnected subsystems, we identified two interrelated analytic categories: (a) preparing for certified practice and (b) the certification process. Within each of these themes, we further identified subcategories that further helped us to illustrate the requirements placed on nursing leaders, barriers to implementing the change, and their strategies in navigating often contradictory and competing work demands.

Preparing for Certified Practice Participants described preparing for the implementation of certified practice as a resource-intensive and, at times, frustrating 5-year process. The nurse leaders noted that although they had been informed by the CRNBC of upcoming regulatory policy changes several years before the regulations were to come into effect, they were limited in their ability to prepare for and respond to these changes. They were specifically limited by the lack of clarity regarding which nursing practice activities would be considered certified practices and how certified practice regulation intersected with the entire spectrum of sexual health care. As one leader noted: It was so confusing . . . what’s certified and what’s not? It is not clear in the communications and we have people thinking “I can’t do that anymore” when in fact the practice they are concerned about is a practice that any nurse can do. Everything [all aspects of sexual health nursing practice] seemed lumped together but in reality it is not. There needs to be better explanation of the categories of practice [certified versus non-certified] . . .

and it needs to be clear how certified practice fits with different collaborative models where we work with physicians and where we work independently. That would have told us a lot earlier who needed certification. Clinics all run a bit differently depending on where you work and the confusion makes it difficult to support us to practice to our full scope and make sure the nurses get certified.

Intersecting system changes. The confusion about the scope of certified nursing practice intersected with many simultaneously occurring system-level changes that exacerbated the nurse leaders’ challenges in preparing to implement the regulatory change. One particularly problematic system-level change was described as the relentless revisions of the new Nurses (Registered) and Nurse Practitioners Regulation that replaced the previous Registered Nurse Act. During the middle years of planning for implementation, the CRNBC, a policy working group, and nurses throughout the province collaboratively identified the need to clarify the expanded nursing practice activities addressed within the newly defined Nurses (Registered) and Nurse Practitioners Regulation, including the restricted activities housed within certified practice. These restricted activities, defined as expanded clinical activities that may present significant harm and therefore reserved for specified professionals (CRNBC, 2012a), were articulated within three regulatory categories of the Nurses (Registered) and Nurse Practitioners Regulation: (a) Section 6: Restricted Activities That Do Not Require an Order (e.g., aspects of wound care, venipuncture, administering oxygen); (b) Section 7: Restricted Activities That Require and Order (e.g., mechanical ventilation, putting an instrument beyond the opening of the urethra); and (c) Section 8: Restricted Activities for Certified Practice (e.g., independently diagnose and treat sexually transmitted diseases, provide birth control; CRNBC, 2012b). The practice activities detailed in Sections 6, 7, and 8 became what nurse leaders referred to as a moving target. The initial categorization of restricted activities in the new regulations was deemed incongruent with current clinical practice, and many activities originally situated within Section 8 required reconsideration to Sections 6 and 7. The ongoing reassignment of activities to differing sections of the regulation contributed to the confusion regarding what Section 8 and therefore certified practice entailed and delayed nurse leaders’ capacities to identify which nurses would require certification within the varying models of health service delivery carried out in their units. Additionally, the provision of sexual health care involved many other disciplines and system-level policies and procedures, for example, provincial laboratory and

Bungay and Stevenson pharmacy services, all of which had operational policies and procedures that warranted revision to support regulatory changes. The leaders expressed frustration at what they described as a disconnect between nursing regulations and the reality of implementing these regulations in the larger health care system in which they worked. As one nurse leader noted: The thing about the change in legislation is that in order to implement it there has to be catch up and that is not going to happen right away. Everything from the labs being able to receive tests ordered by nurses to pharmacy figuring out how the medications can be prepared for nurses to dispense in a manner that does not require a doctor’s order. It is no wonder the initial roll out date got changed. There was so much catch up and change in how things were currently being done.

The disconnect between policies affecting health service delivery and real-time practice contributed to the need for revisions to practice regulation and health system procedures, causing a delayed go-live date and further limited the leaders’ capacities to prepare for the change. The participants acknowledged the importance of clarifying the range of restricted activities and ensuring that these activities were situated within the appropriate section of the regulations. They expressed frustration, however, in that required changes and resultant challenges for the health service delivery system may have been avoided if better consultation between nurses and the CRNBC had occurred during initial regulation planning to allow for accurate descriptions of practice activities within each legislative section. This consultation could have also helped to identify earlier in the planning stages the additional health care systems and programs that needed to be included for policy implementation to occur. Furthermore, the CRNBC was undergoing substantial revision having recently formed as a new regulatory body, replacing the Registered Nurses Association of British Columbia. The ongoing restructuring was experienced by nurse leaders as constant change in CRNBC personnel, job titles, responsibilities, and communication pathways for obtaining information. The net effect was confusion regarding whom they could obtain reliable and consistent information from within the CRNBC. Within the final year, however, communications and collaboration improved, and the CRNBC became viewed by nurse leaders as the central information resource regarding certified practice. In addition to regulatory and CRNBC organizational changes, the health authorities were concurrently undergoing organizational-level restructuring due to health system regionalization. Nurse leaders’ portfolios were being revised; reporting structures among and

73 between nurses were evolving; and the models of sexual health service delivery were being reorganized. In some health authorities, sexual health care was located within public health communicable disease management programs, whereas in others it was integrated into population-based (e.g., youth) primary care services. These different locations exacerbated communication challenges between and within the health authorities’ senior managers, nurse leaders, and the CRNBC. The CRNBC, for instance, requested that one leader in each health authority be identified as the communication representative to share information between the CRNBC and the leader’s entire health authority. The participants described this request as impossible. They reported infrastructure limitations and collaboration and communication challenges between themselves and other leaders within their respective health authorities, a situation they did not see changing in the foreseeable future. Additionally, there was substantial diversity in the roles and responsibilities for the nurse leaders with regard to policy implementation. Some were responsible for an entire health service delivery area and managed a large number of clinical settings and staff, whereas others had responsibilities to individual programs. For those with large portfolios, they reported having limited information regarding the day-to-day practice of nurses in these settings, and this contributed to uncertainty regarding the need for certified practice. Additionally, the leaders experienced different responsibilities in relation to policy implementation. It was not uncommon, for example, for one leader to have fiscal planning responsibilities (e.g., budget decisions) and another to have professional development responsibilities (e.g., identifying nurses requiring certification) within the same health authority. Making it work. Despite the confusion regarding the expanded nursing activities that required certification, the abundant communication challenges, and differing responsibilities, the nurse leaders recognized that implementing a new regulatory policy required serious work to promote quality nursing practice and ensure that clients at risk for or experiencing STIs still received health care. The nurse leaders assumed the responsibility for developing and leading working groups that included frontline nurses and other nurse leaders to develop what they termed a rollout plan. These working groups were resource intensive, a situation exacerbated by health care programming cuts and the limited access to additional fiscal or human resources to support the implementation process. In some instances, a practice lead was removed from his or her regular work responsibilities and assigned to coordinate policy implementation. This leader was not often replaced to undertake this work, and his or her previous projects and activities were either put on hold or added to an already-full workload.

74 The secondment of a practice leader occurred more often in health service delivery areas that were urban, had substantial professional development resources (e.g., clinical educators), and in sexual health-specific clinic settings versus generalist nursing sites. Rural nurse leaders noted what they termed as the never-ending resource discrepancies between their programs and their urban counterparts, a situation that directly affected their ability to support policy implementation. The leaders expressed concerns about the ability to maintain their current health services during the planning phase and described the entire process as incredibly stressful. The certification process. Once there was a definitive statement from the CRNBC that certified practice entailed the independent diagnosis and treatment of a range of STIs and the related restricted activities including administering, compounding, or dispensing Schedule I medications (CRNBC, 2010), nurse leaders focused on ensuring that frontline nurses obtained certification. Certification was achieved through distinct pathways: (a) a practice experience assessment completed by the employer and assessed by the CRNBC, (b) successful completion of a CRNBC-approved challenge examination, and (c) successful completion of a CRNBC-approved education course. Additionally, nurses who could provide proof of successful completion of an educational course offered through the Provincial Health Services Authority (PHSA), BC Centre for Disease Control (BCCDC) during 2005–2010 were eligible to be grandfathered in to the certification registry. As the nurse leaders assumed the primary role in translating these pathways into supporting nurses to achieve certification, they experienced grave challenges that ultimately influenced their human resource management strategies and their decisions regarding sexual health nursing service delivery. Access to education. Two CRNBC-approved STI-certified practice courses were available to support nurses’ certification for STI diagnosis and treatment. One was offered through the PHSA (see BCCDC, 2013) and the other via the British Columbia Institute of Technology (BCIT) in partnership with Options for Sexual Health, a nonprofit provider of sexual health services in British Columbia (see BCIT, 2013). Both courses included an online 12-week theory course and a 3-day clinical practicum. The courses differed, however, in enrollment capacity, frequency of course offerings, tuition and travel costs, clinical practicum availability and quality, and the breadth of topics addressed in the theory components. The PHSA course, offered through the BCCDC, had zero tuition fees and the clinical practicum was provided in the agency’s specialized STI clinic setting. The learners were preceptored by experienced and certified nurses

Policy, Politics, & Nursing Practice 14(2) who had taken preceptorship training to support them in their clinical teaching roles. The tuition waver was based on the health authority’s mandate and funding to support practitioners provincially and illustrated BCCDC’s multidecade history of providing education to health care professionals. Entry into the program required written support from an applicant’s manager, and the costs for travel for the clinical practicum were not covered by the PHSA. The course was (and is) offered four times per year with a maximum capacity of 20 enrollees per course offering, of which 12 positions were allocated for the clinical practicum per course offering (BCCDC, 2013). BCIT, a degree-granting institution, charged $757.12 and $505.18 CAN for theory and clinical courses, respectively (BCIT, 2013). Credits obtained by taking these courses could be applied to a degree program. The clinical practicum was offered as a preceptorship at collaborating clinical agencies, and a minimum of six students were required to offer the theory course. The course was (and is) offered at least three times per year. Most of the nurse leaders expressed a preference for the BCCDC course based on their perceptions that it was more comprehensive than the BCIT program regarding the spectrum of STI care, for instance, theory specific to sexuality and partner notification. As one leader noted: You need to learn more than about diseases . . . one nice thing about the BCCDC course is it has content on health sexuality and homophobia and taking a look at your values. It isn’t just about the swab.

The participants also appreciated that the BCCDC course provided the clinical training in a specialized STI clinic that was part of the provincial Centre for Disease Control. The preference for the BCCDC clinical practicum was further substantiated by their concerns regarding the limited clinical placement options available within the BCIT practicum. Nurse leaders’ preferences for BCCDC education, however, did not prohibit them from paying for nurses to undertake the BCIT course. Many of the leaders noted negligible cost differences between the two courses when the travel costs associated with BCCDC’s clinical practicum in Vancouver were taken into consideration. They also acknowledged that the BCIT program overcame issues of limited accessibility and autonomy that they associated with the BCCDC course. BCCDC, for example, was reported to have long wait lists and limited the number of nurses’ per health authority enrolled in each course offering as compared with open enrollment at BCIT. Additionally, nurses who wished to obtain certification at their expense or as part of their postdiploma baccalaureate degree were not restricted by an employer’s endorsement, and the nurse leaders viewed this option as extremely positive from a human resource

Bungay and Stevenson and cost–benefit perspective. They expressed that certified nurses were more competitive in the current job market and actively sought to hire people with certified practice registration. Despite the pros and cons for both institutions’ course offerings, limited access to clinical practicums was a major obstacle in supporting nurses to obtain the necessary certification. The BCCDC’s limited teaching clinical capacity and the lack of suitable placements for BCIT learners exacerbated access problems. The nurse leaders expressed a need for education to prepare nurses in clinical agencies throughout the province to assume clinical teaching roles but were uncertain as to with whom this responsibility rested. Leaders from health authorities that offered in-house orientation and STI education for nurses prior to certification regulations expressed dismay that these programs were not recognized by the CRNBC. Leaders in one health authority, at the time of the study, were collaborating with educational programs to develop in-house clinical practicums that met the CRNBC requirements for certified practice. For nurse leaders with nurses whose responsibilities covered vast geographical areas and rural communities and who had minimal funding for educational activities, developing a collaborative clinical practicum was not feasible. Human resource and fiscal costs for certification. Implementation of certified practice regulations required the nurse leaders to juggle complex and intersecting fiscal and human resource concerns. Many of the nurses who worked in STI diagnosis and treatment, for instance, worked in generalist public health roles. The daily workload for generalist nurses was often dictated by the public health needs of the communities in which they worked, for instance, outbreaks of infectious diseases (e.g., tuberculosis, pertussis, meningitis). The complex work demands placed on frontline nurses created substantial workforce issues for nurse leaders as they struggled to support nurses to have the professional development time to undertake the certified practice education while simultaneously maintaining the range of public health services offered in their programs. Supporting nurses’ professional development and maintaining service delivery were further complicated by limited fiscal support for nursing professional development activities and recent budget cuts that limited nurse leaders’ capacities to address replacement staffing needs. Institutional hiring freezes and no travel policies further challenged nurse leaders’ abilities to implement certified practice regulation, contributing in some instances to nurse leaders’ decisions to limit STI diagnosis and treatment services provided by nurses. These limitations included a reduced number of nurses practicing in sexual health care, thereby reducing the number requiring certification; reduced clinic hours for clients seeking

75 STI care; or in some cases, discontinuation of sexual health services altogether. Where services were discontinued, a referral policy was implemented in which clients who sought STI care were referred to a walk-in clinic or their primary care provider. The nurse leaders recognized that referrals could negatively affect some peoples’ access to care, but they believed that there was no choice given the increasing workloads for public health nurses’ generally and the reduced fiscal and professional development supports necessary to implement the new regulations.

Discussion Our research provided insight into nurse leaders’ experiences of implementing a regulatory policy change in a public health context, thereby contributing to the growing scholarship concerned with the role of nursing leadership in policy implementation (Heward et al., 2007). Similar to Shanley (2007) and Ganann et al. (2010), we illustrated that nurse leader engagement was paramount to effective policy implementation. Our research also concurred with Knight and Corkill (2003) in that regulatory policy changes were important for nursing autonomy and to support a normative evidence-based practice for effective patient care. Our research, however, diverged from the predominant policy implementation research concerned with nursing practice (e.g., Heward et al., 2007) in distinct ways. To date, the majority of Canadian research has emphasized expanded practice activities in advanced practice roles requiring graduate-level education such as nurse practitioners and clinical nurse specialists (e.g., Di Censo et al., 2010). Additionally, the international research in regulations governing expanded activities has focused on acute care settings (e.g., Palumbo, Marth, & Rambur, 2011), thereby having overlooked public health nursing (Stevenson, 2012). Situated within a public health context, we demonstrated that the multiplicity of roles and responsibilities of public health nurses acted as a barrier to effective policy implementation. Although the role complexity for public health nurses has been well established (Bungay, 2010; Underwood et al., 2009), to our knowledge this complexity has not been previously discussed in policy research. Thus, our findings illustrated important contextual factors regarding competing job demands and resultant human resource and workforce issues that can inform future policy implementation strategies within the public health context. Furthermore, by investigating regulatory frameworks for expanded practice in public health settings, we identified important issues for additional research to compare and contrast regulatory policy implementation within diverse health care settings and nursing roles.

76 Another area of divergence that we considered pertained to concurrent health system changes and practices. By having situated our work within a framework that identified the health care system and regulatory organizations as complex adaptive systems, we demonstrated the importance of understanding the contrasting and competing demands of the health systems and regulatory organizations for regulation policy implementation. These new insights were critical to discerning interrelated barriers and supports for effective policy change as well as the deleterious unintended consequences that, in some instances, negatively affected the delivery of nursing care. Although evidence locally and internationally has shown inconsistency in models of nursing practice, educational qualifications, and legal frameworks governing sexual health care and has garnered recommendations for regulatory changes (Knight & Corkill, 2003; Wearing & Nickerson, 2010), we concur with Head’s (2009) caution against policy processes that hinder nurses’ ability to meet the public’s health care needs. Instead, regulatory policy implementation must take into consideration the broader health care systems in which nurses practice. The unintended consequences of limiting nurses’ capacities to meet the public’s health care needs, for instance, raised concerns regarding intersections between the regulatory frameworks, the diversity in the organization and delivery of nursing care, and the pressing public health issues associated with STIs. STIs remain serious global health concerns that have been associated with infertility, cancer, HIV, and AIDS (Steenbeek, Tyndall, Sheps, & Rothenberg, 2009). Those who carry the greatest burden for STIs frequently do not access mainstream services such as family physicians (Shoveller et al., 2009). Public health nurses are the largest public health work force (Naylor, 2003) and an essential component of sexual health care (Bungay, 2010). The oversights by the regulatory body in the initial policy planning activities described by the participants appeared in contrast to Head’s (2009) recommendations, contributing to reduced sexual health care services and the potential for deleterious health consequences. The CRNBC’s preliminary strategies were disconnected from the local politics in which sexual health nursing practice occurred. Stakeholders had limited participation in policy design which further contributed to nursing role confusion and communication challenges regarding implementation. These oversights exacerbated misunderstanding and nurse leaders’ mistrust of the CRNBC, thereby limiting the collaborative efforts necessary for regulatory policy implementation (Cummings & McLennan, 2005; Shanta & Kalanek, 2008). Additionally, policy implementation frameworks such as those set out by Hanley and Falk (2011) have noted that implementation, to be effective, should integrate empirical and local knowledge regarding nursing practice

Policy, Politics, & Nursing Practice 14(2) and organizational barriers that can affect implementation success. The initial policy implementation strategies appeared disconnected from the compelling research evidence and the local contexts regarding limited professional development opportunities for nurses, particularly in rural and remote communities (see Bungay, 2010; Meagher-Stewart et al., 2010; Underwood et al., 2009). Given the complex intersections between work environments and regulations deemed necessary for patient care, issues of responsibility for ensuring effective policy implementation were raised, as discussed in the subsequent recommendations.

Limitations and Recommendations Our research was limited by the small sample size and minimal input of the multiple stakeholders engaged in regulatory policy implementation. Despite these limitations, we were able to address some important issues in regulatory policy implementation, particularly for nurses working in expanded practice activities that do not require graduate-level education. The recommendations we put forth in this article were designed to expand the research in this topic area and to assist in the growing evidence of the need for evidence-informed policy implementation strategies that can help advance the knowledge of regulatory policy change and support effective implementation in a manner that enhances versus limits the public’s access to health care. With these ideas in mind, we recommend that there is an urgent need for further research to identify the roles and responsibilities of the various stakeholders involved in supporting policy implementation. This research must emphasize strategies to address the fiscal and human resources necessary to support implementation as well as the leadership responsibilities of professional and regulatory organizations in supporting the regulatory policy changes that they initiate. We also recommend that simultaneous work is needed to determine the effectiveness of regulatory changes in protecting the public from harm while simultaneously improving health service delivery. Finally, as has been illustrated in previous research concerned with the impact of health system restructuring for quality nursing care, work environments must support and sustain nurses’ professional development opportunities. Without the educational support to promote evidence-informed quality nursing practice, nurses may be limited to practice to the full scope of their abilities with negative consequences for the health of the public.

Acknowledgments The authors thank all the nurse leaders who participated in the study for their time and insights.

Bungay and Stevenson Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this research was provided by the Lyle Creelman Endowment Fund for Public Health Research. Dr Bungay is supported by the Michael Smith Foundation for Health Research Scholar Award.

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Author Biographies Vicky Bungay, PhD, RN is an Assistant Professor and Michael Smith Foundation for Health Research Scholar in the School of Nursing at the University of British Columbia, Canada. Her program of research is concerned with sexual health promotion and quality nursing practice. Janine Stevenson, MSN, RN is a Nurse Educator with the British Columbia Centre for Disease Control, Division of Sexually Transmitted Infection Prevention and Control. Janine has extensive experience in outreach nursing in urban and rural settings with a particular emphasis in HIV and STI prevention.

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