Regulating health professional scopes of practice: comparing institutional arrangements and approaches in the US, Canada, Australia and the UK.

BACKGROUND: Fundamentally, the goal of health professional regulatory regimes is to ensure the highest quality of care to the public. Part of that task is to control what health professionals do, or their scope of practice. Ideally, this involves the application of evidence-based professional standards of practice to the tasks for which health professional have received training. There are different jurisdictional approaches to achieving these goals. METHODS: Using a comparative case study approach and similar systems policy analysis design, we present and discuss four different regulatory approaches from the US, Canada, Australia and the UK. For each case, we highlight the jurisdictional differences in how these countries regulate health professional scopes of practice in the interest of the public. Our comparative Strengths, Weaknesses, Opportunities, Threats (SWOT) analysis is based on archival research carried out by the authors wherein we describe the evolution of the institutional arrangements for form of regulatory approach, with specific reference to scope of practice. RESULTS/CONCLUSIONS: Our comparative examination finds that the different regulatory approaches in these countries have emerged in response to similar challenges. In some cases, 'tasks' or 'activities' are the basis of regulation, whereas in other contexts protected 'titles' are regulated, and in some cases both. From our results and the jurisdiction-specific SWOT analyses, we have conceptualized a synthesized table of leading practices related to regulating scopes of practice mapped to specific regulatory principles. We discuss the implications for how these different approaches achieve positive outcomes for the public, but also for health professionals and the system more broadly in terms of workforce optimization.

The role of natural health products (NHPs) in dietetic practice: results from a survey of Canadian dietitians.

BACKGROUND: Registered dietitians (RDs) play a key role in disseminating information about nutrition and intervening in nutrition-related disorders in the Canadian context. Natural health products (NHPs) are increasingly associated with nutrition in patient and health professional discussions. For this study, NHPs were divided into three categories: nutritional supplements (NS); functional foods/nutraceuticals (FF/N); and herbal preparations (HP). The objective was to explore RDs' perceptions about their professional roles and responsibilities with respect to three categories of natural health products (NHPs). METHODS: This research consisted of an on-line survey of registered dietitians (RDs) in Ontario.Surveys were distributed electronically to all practicing RDs in Ontario by the College of Dietitians of Ontario. There were 558 survey respondents, a response rate of 20%. RESULTS: The vast majority of RDs reported being consulted by clients about all product categories (98% for NS; 94% for FF/N; 91% for HP), with RDs receiving the most frequent questions about NS and the least frequent about HP. 74% of RDs believed that NS are included within the current scope of practice, compared to 59% for FF/N and 14% for HP. Even higher numbers believed that these products should be included: 97% for NS, 91% for FF/N and 47% for HP. RDs who report personally ingesting FF/N and HP were significantly more likely to report that these products should be in the dietetic scope of practice. In contrast, RDs who provide one-on-one counselling services or group-level counselling/workshops were significantly less likely to believe HP should be in the dietetic scope of practice. CONCLUSIONS: Opinions of RDs indicated that NS and FF/N (and possibly HP) fall within, or should fall within, RDs' scope of practice. Opportunity exists for RDs to undertake a professional role with respect to NHPs. Policy clarification regarding RD roles is needed.

Roles and responsibilities of pharmacists with respect to natural health products: key informant interviews.

BACKGROUND: Although many pharmacies sell natural health products (NHPs), there is no clear definition as to the roles and responsibilities (if any) of pharmacists with respect to these products. OBJECTIVE: The purpose of this study was to explore pharmacy and stakeholder leaders' perceptions of pharmacists' professional NHP roles and responsibilities. METHODS: Semi-structured key informant interviews were conducted with pharmacy leaders (n=17) and stakeholder (n=18) leaders representing consumers, complementary and alternative medicine practitioners, conventional health care practitioners, and industry across Canada. RESULTS: All participants believed a main NHP responsibility for pharmacists was in safety monitoring, although a one challenge identified in the interviews was pharmacists' general lack of NHP knowledge; however, stakeholder leaders did not expect pharmacists to be experts, but should have a basic level of knowledge about NHPs. CONCLUSION: Participants described pharmacists' professional roles and responsibilities for NHPs as similar to those for over-the-counter drugs; more awareness of existing NHP-related pharmacy policies is needed, and pharmacy owners/managers should provide additional training to ensure front-line pharmacists have appropriate knowledge of NHPs sold in the pharmacy.

Canadian family physicians and complementary/alternative medicine: the role of practice setting, medical training, and province of practice.

The present study sheds some light on how and why Canadian family physicians offer complementary and alternative medicine (CAM) services to their patients. Our results suggest that organizational settings discourage physicians from offering CAM, while solo clinics are most conducive. Physicians trained in French-language medical schools are less likely than their English-language trained colleagues to offer CAM services, and those in British Columbia are the most likely to do so. Provincial differences do not appear to be related to the presence or absence of "negative proof" legislation that is considered to facilitate CAM provision by physicians.

Unique aspects of herbal whole system research.

INTRODUCTION: Whole systems of healthcare offer unique methodological and theoretical challenges for researchers. Herbalism has its own set of methodological and philosophical research issues that are beyond those presented for whole system research in general. It was our objective to explore various conceptual and methodological issues surrounding whole system herbal research. METHODS: An International Society for Complementary Medicine Research workshop, Challenges in Herbal Whole System Research, was presented. Starting from a definition of herbalism, the most important challenges to herbal whole system research were elicited with inputs from both the workshop presenters and the audience. RESULTS: Five major challenges unique to herbal whole system research were identified: (1) defining herbalists and herbalism, (2) the role of the natural products industry in herbal research, (3) designing placebos and delivering active herbal treatments as given by herbalists, (4) researching the herb as a living entity, and (5) designing trials to investigate and develop multicomponent herbal therapies. CONCLUSIONS: Unique methods and theoretical frameworks are required to design studies of herbalism. Solutions to these methodological challenges need to be addressed to conduct research that examines herbal systems of medicine versus conducting trials on individual herbs given out of their original therapeutic context.

The ethics of dietary supplements and natural health products in pharmacy practice: a systematic documentary analysis.

OBJECTIVES: Many natural health products and dietary supplements are purchased in pharmacies and it has been argued that pharmacists are in the best position to provide patients with evidence-based information about them. This study was designed to identify how the pharmacist's role with respect to natural health products and dietary supplements is portrayed in the literature. METHOD: A systematic search was conducted in a variety of health databases to identify all literature that pertained to both pharmacy and natural health products and dietary supplements. Of the 786 articles identified, 665 were broad-coded and 259 were subjected to in-depth qualitative content analysis for emergent themes. KEY FINDINGS: Overwhelmingly, support for the sale of natural health products and dietary supplements in pharmacies is strong. Additionally, a role for pharmacist counselling is underscored. But another recurrent theme is that pharmacists are ill-equipped to counsel patients about these products that are available on their shelves. This situation has led some to question the ethics of pharmacists selling natural health products and dietary supplements and to highlight the existence of an ethical conflict stemming from the profit-motive associated with sales of natural health products and dietary supplements. CONCLUSIONS: This analysis raises concerns about the ethics of natural health products and dietary supplements being sold in pharmacies, and about pharmacists being expected to provide counselling about products of which they have little knowledge.

Exploring consumer and pharmacist views on the professional role of the pharmacist with respect to natural health products: a study of focus groups.

BACKGROUND: Natural health products (NHPs) such as herbs, vitamins and homeopathic medicines, are currently available for sale in most Canadian pharmacies. However, most pharmacists report that they have limited knowledge about these products which have been regulated in Canada as a specific sub-category of drugs. In this paper, consumers' and practicing pharmacists' perceptions of pharmacists' professional responsibilities with respect to NHPs are examined. METHODS: A total of 16 focus groups were conducted with consumers (n = 50) and pharmacists (n = 47) from four different cities across Canada (Vancouver, Edmonton, Toronto, and Halifax). RESULTS: In this paper, we illustrate the ways in which pharmacists' professional responsibilities are impacted by changing consumer needs. Many consumers in the study utilized a wide range of information resources that may or may not have included pharmacists. Nevertheless, the majority of consumers and pharmacists agreed that pharmacists should be knowledgeable about NHPs and felt that pharmacists should be able to manage drug-NHPs interactions as well as identify and evaluate the variety of information available to help consumers make informed decisions. CONCLUSION: This paper demonstrates that consumers' expectations and behaviour significantly impact pharmacists' perceptions of their professional responsibilities with respect to NHPs.

U.S. and Canadian pharmacists' attitudes, knowledge, and professional practice behaviors toward dietary supplements: a systematic review.

BACKGROUND: Although dietary supplements (DS) are widely sold in pharmacies, the legal, ethical, and practice responsibilities of pharmacists with respect to these products have not been well defined. This systematic review of pharmacists' attitudes, knowledge, and professional practice behaviours toward DS is intended to inform pharmacy regulators' and educators' decision making around this topic. METHODS: Eligible studies were identified through a systematic database search for all available years through to March 2006. Articles were analyzed for this review if they included survey data on U.S. or Canadian pharmacists' attitudes, knowledge, or professional practice behaviors toward DS published in 1990 or later. RESULTS: Due to the heterogeneity of the data, it was not possible to draw a conclusion with respect to pharmacists' general attitudes toward DS. Approximately equal numbers of pharmacists report positive as well as negative attitudes about the safety and efficacy of DS. There is strong agreement among pharmacists for the need to have additional training on DS, increased regulation of DS, and quality information on DS. In addition, survey data indicate that pharmacists do not perceive their knowledge of DS to be adequate and that pharmacists do not routinely document, monitor, or inquire about patients' use of DS. Despite this, a large proportion of pharmacists reported receiving questions about DS from patients and other health care practitioners. CONCLUSION: Further research is needed to explore the factors that influence pharmacists' beliefs and attitudes about DS, to accurately evaluate pharmacists' knowledge of DS, and to uncover the reasons why pharmacists do not routinely document, monitor, or inquire about patients' use of DS.

Exclusive versus everyday forms of professional knowledge: legitimacy claims in conventional and alternative medicine.

In this paper I present a model of professional knowledge forms that accounts for the different, and sometimes contradictory, ways in which medical doctors (MDs) and various complementary and alternative medicine (CAM) practitioners define their competencies and make legitimacy claims. The first section provides a schema for problematising knowledge and its relationship to legitimacy by distinguishing between the context, form and content of professional knowledge. I draw particularly upon Jamous and Peloille's (1970) distinction between the technical or indeterminate forms of professional knowledge. I argue that their characterisation might be enriched by attending to dimensions of 'exclusive' versus 'everyday' knowledge forms. In particular, I point out that both technical and indeterminate forms are amenable to exclusion, or conversely can be made accessible as everyday knowledge. Both forms can thus be employed in attempts to legitimate professional practice. In the final section, I map the current context of CAM and biomedicine onto this expanded professional knowledge map.