Clause by clause overview of draft regulation under the Nursing Act, 1991 The chart below shows the proposed regulation changes, and rationale, for RN prescribing, nurse dispensing and nurse administration: 16. (1) A member shall not engage in conduct that results, directly or indirectly, in a personal or financial benefit that conflicts with his or her professional or ethical duty to a patient as a result of prescribing, dispensing, selling or compounding a drug. 16. (2) A member who prescribes, dispenses, sells or compounds a drug shall comply with all applicable federal and provincial law related to prescribing, dispensing, selling or compounding a drug. No change No change 16. (3) A member who is authorized to prescribe, dispense, sell or compound a drug shall not delegate the performance of prescribing, dispensing, selling or compounding a drug to any other person. 16. (3) A member who is authorized to prescribe, dispense, sell or compound a drug shall not delegate the performance of prescribing, dispensing, selling or compounding a drug to any other person. Housekeeping to remove duplication and place all delegation provisions in Part V (Delegation) of the regulation, which is entirely focussed on delegation. Part V currently prohibits: RNs and RPNs from delegating the controlled act of dispensing a drug. NPs from prescribing, dispensing, selling and compounding a drug Additional changes are proposed to section 35(4), which is in Part V of the regulation, to prohibit an RN from delegating the new controlled acts of prescribing and communicating a
diagnosis to another person. Council supported this policy in March 2018. 16. (4) A member who is authorized to prescribe, sell or compound a drug shall not prescribe, sell or compound a controlled substance except where authorized by subsection 17 (2). Not applicable (new section) 17. (1) For the purposes of paragraph 8 of subsection 5.1 (1) of the Act, a member may only prescribe a drug if all of the following conditions are met: 1. The member must have a nursepatient relationship with the patient for whom the drug is prescribed. 2. The member must prescribe the drug for therapeutic purposes only. 16. (4) (3) A member who is authorized to prescribe, sell or compound a drug shall not prescribe, sell or compound a controlled substance except where authorized by subsection 17 (23). 17. (1) A member who is a registered nurse in the General class is authorized to prescribe a drug set out in Schedule 4 or a drug from within a category of drugs set out in Schedule 4, if the member meets all of the requirements in this section. 17 (2) A member who is a registered nurse in the General or extended class may only prescribe a drug if all of the following conditions are met: 1. The member must have a nurse-patient relationship with the patient for whom the drug is prescribed. 2. The member must prescribe the drug for therapeutic purposes only. Numbering adjustments. Section 17 is about prescribing medication, which currently only applies to NPs. It is redrafted to incorporate RN prescribing. This section permits a RN to prescribe a drug (or drug from within a category) in the schedule, if the RN meets the requirements for public protection set out in the section. The Nursing Act, 1991 requires that the regulation specify the drugs an RN is authorized to prescribe; the regulation may specify individual drugs, or drug categories. Currently, 17(1) references a section of the Nursing Act that applies to NPs. It is redrafted to apply to NP and RN prescribing. Paragraphs 1-4 are practice expectations for prescribing medication. With the change in 17(2), these expectations will apply to both NP and RN prescribing.
3. The member must ensure that the following information is recorded on the prescription: i. the name and address of the person for whom the drug is prescribed, ii. the name, strength (where applicable) and quantity of the drug that is prescribed, iii. the directions for use, iv. the member s name, address, telephone number, title and registration number issued by the College, v. the member s signature, vi. the date on which the drug is prescribed, and vii. the number of refills, if applicable. 3. The member must ensure that the following information is recorded on the prescription: i. the name and address of the person for whom the drug is prescribed, ii. the name, strength (where applicable) and quantity of the drug that is prescribed, iii. the directions for use, iv. the member s name, address, telephone number, title and registration number issued by the College, v. the member s signature, vi. the date on which the drug is prescribed, and vii. the number of refills, if applicable. 4. The member must retain a copy of the information recorded on the prescription required under paragraph 3 as part of the patient s health record. 4. The member must retain a copy of the information recorded on the prescription required under paragraph 3 as part of the patient s health record. Therapeutic purpose is defined broadly and includes medication used for any patient health care need, including treatment, disease prevention, health promotion, symptom management or lifestyle/choice. Council reviewed these expectations, among other accountabilities, in June 2018. 17.(2) For the purposes of paragraph 8 of subsection 5.1 (1) of the Act, a member who meets the conditions set out in subsection (1) of this section is authorized to prescribe a controlled substance if the member satisfies the Executive Director that the member has, within any time period set by Council, successfully completed education approved by Council that was specifically designed to educate registered nurses in the extended class to safely, effectively 17. (2) For the purposes of paragraph 8 of subsection 5.1 (1) of the Act, a member who meets the conditions set out in subsection (1) 17. (3) A member who is a registered nurse in the extended class who meets the conditions set out in subsection (2) of this section is authorized to prescribe a controlled substance if the member satisfies the Executive Director that the member has, within any time period set by Council, successfully completed education approved by Council that was specifically designed to educate registered nurses in the extended class to Revisions for consistency: the regulatory amendments to permit RN prescribing consolidate the prescribing and related rules for RNs and NPs and refer to RNs or NPs (or RPNs) as the situation requires, without reference to the Nursing Act. Numbering adjustments to ensure the regulation references the appropriate provision.
and ethically prescribe controlled substances. 17. (3) The education mentioned in subsection (2) may be education that is either independent of or part of the education and training required to become a registered nurse in the extended class. Not applicable (new section) safely, effectively and ethically prescribe controlled substances. 17.(3) (4) The education mentioned in subsection (2) (3) may be education that is either independent of or part of the education and training required to become a registered nurse in the extended class. 17. (5) Where a route of administration or other specification is indicated with respect to a drug or category of drugs listed in Schedule 4, a member who is a registered nurse in the General class and authorized to prescribe a drug shall only prescribe the drug in compliance with the specification and in accordance with the route of administration. 17(5) Some drugs / drug categories listed in schedule 4 include parameters; for example, some can only be prescribed for topical use (applied to an area of the body). This provision makes clear that RNs are only permitted to prescribe in accordance with those parameters. Council first identified these parameters in-principle in September 2017; and reviewed them for specific drugs/drug categories in June and September 2018. Not applicable (new section) 17. (6) A member who is a registered nurse in the General class shall not prescribe any drug unless the member, (a) has successfully completed education approved by Council that was specifically designed to educate registered nurses to safely, effectively and ethically prescribe drugs; or (b) is taking part in the education mentioned in clause (a) and prescribes the drug under the Paragraph (a) allows RNs who successfully complete Council-approved education to prescribe. Council will be asked to approve education in the future. Paragraph (b) will allow RNs who are enrolled in Council-approved education to prescribe under supervision. This is meant to support their learning. In keeping with the system s movement towards inter-professional education and practice, supervisors can be any regulated health professional who is
supervision of a person who is authorized to prescribe the drug under a health profession Act as defined in the Regulated Health Professions Act, 1991. authorized to prescribe the medication. In the future this will include RNs who are authorized to prescribe. Not applicable (new section) Not applicable (new section) 17. (7) A member who is a registered nurse shall not perform the controlled act of communicating to a patient or his or her representative a diagnosis made by the member where the purpose of that communication is for prescribing a drug, unless that member, (a) meets the condition required in clause (6) (a); or (b) is taking part in the education mentioned in clause (6) (a) and communicates the diagnosis under the supervision of a person who is authorized to prescribe the drug and communicate a diagnosis under a health profession Act as defined in the Regulated Health Professions Act, 1991. 18. (1) A member who is a registered nurse or a registered practical nurse may dispense a drug set out in Schedule 4 or a drug from within a category of drugs set out in Schedule 4 pursuant to a prescription issued by a registered nurse in the General class who is authorized to prescribe the drug. Only RNs who are permitted to prescribe medication may perform the controlled act of communicating a diagnosis for the purpose of prescribing. Paragraph (b) will allow RNs who are enrolled in Council-approved education to perform this controlled act under supervision. This is meant to support their learning. In keeping with the system s movement towards inter-professional education and practice, supervisors can be any regulated health professional who is authorized to communicate diagnoses and prescribe the medication. In the future this will include RNs who are authorized to prescribe. Section 18 is redrafted to add authorities related to RN prescribing, consolidate dispensing requirements for all nurses, and remove conditions on NP dispensing. Currently, under the Nursing Act, 1991 RNs and RPNs may only dispense medication that have been prescribed by a physician, NP or dentist. This provision
also permits an RN or RPN to dispense a medication that is prescribed by an RN who is authorized. Council supported this policy in March 2018. This provision allows an RN, who is authorized to prescribe, to also dispense a medication s/he has prescribed. Council supported this policy in December 2017. 18. (1) For the purposes of paragraph 8 of subsection 5.1 (1) of the Act, a member may only dispense a drug if all of the following conditions are met: 18. (1) 1. The member must have a nurse-patient relationship with the patient for whom the drug is dispensed. 18. (1) For the purposes of paragraph 8 of subsection 5.1 (1) of the Act, a member may only dispense a drug if all of the following conditions are met: 18. (2) A member may only dispense a drug if all of the following conditions are met: 18. (12) 1. The member must have a nurse-patient relationship with the patient for whom the drug is dispensed. Currently, 18(1) references a section of the Nursing Act that applies to NPs, it is redrafted to remove some provisions (explained below) and also to make any nurse (RPN, RN, NP) who dispenses a medication subject to the same practice accountabilities. In December 2017, Council supported the principle of promoting consistency in dispensing standards for nurses. Currently this regulation only applies to NPs. With the revision to 18(1) described above, this regulation will apply to any nurse when dispensing medication. This is not a change in practice, it is currently an expectation that a nurse (RPN, RN, NP) only dispense medication in the context of providing professional services to clients for the purpose of meeting patient care needs. Council reviewed this standard (among others) in June 2018.
18. (1) 2. The member must not dispense a drug pursuant to a prescription issued by any other person. 18. (1) 3. The member must provide the drug directly to the patient or the patient s representative. 18. (1) 2. The member must not dispense a drug pursuant to a prescription issued by any other person. 18. (12) 32. The member must provide the drug directly to the patient or the patient s representative. Currently, the regulation prohibits NPs from dispensing medication that is prescribed by another health professional, such as a physician. This regulation has unintended consequences: it impedes care in environments where physicians and NPs work collaboratively. RPNs and RNs continue to require prescriptions from specified health professionals before dispensing medication. (In December 2017, Council supported the principle of promoting consistency in dispensing standards for nurses.) This regulation does not target risk: given the other regulations and standards that will be in place to promote safe dispensing, this regulation does not provide additional safety. Council reviewed this proposed change (among others) in June 2018. Currently this regulation only applies to NPs. With the revision to 18(1) described above, this regulation will apply to any nurse when dispensing medication. This regulation reduces the risk of medication diversion and promotes opportunities for client education.
Council reviewed this standard (among others) in June 2018. 18. (1) 4. The member must dispense the drug for therapeutic purposes only. 18. (12) 43. The member must dispense the drug for therapeutic purposes only. Currently this regulation only applies to NPs. With the revision to 18(1) described above, this regulation will apply to any nurse when dispensing medication. This is not a substantive change in practice, it is currently an expectation of any nurse (RPN, RN, NP) that they only dispense medication to meet their patients health needs. Therapeutic purpose is defined broadly and includes medication used for any patient health care need, including treatment, disease prevention, health promotion, symptom management or lifestyle/choice. Council reviewed this standard (among others) in June 2018. 18. (1) 5. The member must have made reasonable inquiries and be satisfied that, i. the patient does not have reasonable or timely access to a pharmacy, ii. the patient would not otherwise receive the drug, iii. the patient does not have the financial resources to obtain the drug if it is not dispensed by the member, 18. (1) 5. The member must have made reasonable inquiries and be satisfied that, i. the patient does not have reasonable or timely access to a pharmacy, ii. the patient would not otherwise receive the drug, iii. the patient does not have the financial resources to obtain the drug if it is not dispensed by the member, Currently, the regulation only permits NPs to dispense medication in certain circumstances. This regulation may have unintended consequences: impeding patient access to care and/or choice. This regulation does not target risk: given the other regulations and standards that will be in place to promote safe
iv. the drug is being dispensed for a patient in conjunction with a health promotion initiative, or iv. the drug is being dispensed for a patient in conjunction with a health promotion initiative, or v. dispensing the drug is necessary to test the patient s response to the drug. 18. (1) 6. The member must dispense a reasonable quantity of the drug having regard to the information provided by the patient in response to the inquiries under paragraph 5. 18. (1) 7. The member must have reasonable grounds to believe that the drug has been obtained and stored in accordance with any applicable legislation. v. dispensing the drug is necessary to test the patient s response to the drug. 18. (1) 6. The member must dispense a reasonable quantity of the drug having regard to the information provided by the patient in response to the inquiries under paragraph 5. 18. (12) 74. The member must have reasonable grounds to believe that the drug has been obtained and stored in accordance with any applicable legislation. dispensing, this regulation does not provide additional safety. Council reviewed this proposed change (among others) in June 2018. If paragraph 5 is removed, this regulation is no longer relevant. Currently this regulation only applies to NPs. With the revision to 18(1) described above, this regulation will apply to any nurse when dispensing medication. It is currently an expectation of any nurse (RPN, RN, NP) to promote and/or implement safe medication storage. This regulation reduces risk that unsafe medication will be used in patient care. Council reviewed this standard (among others) in June 2018. 18. (1) 8. The member must be satisfied that the drug has not expired and will not expire before the date on which the patient is expected to take the last of the drug. 18. (12) 85. The member must be satisfied that the drug has not expired and will not expire before the date on which the patient is expected to take the last of the drug. Currently this regulation only applies to NPs. With the revision to 18(1) described above, this regulation will apply to any nurse (RPN, RN, NP) when dispensing medication. This regulation reduces risk that unsafe medication will be used in patient care. Council reviewed this standard (among others) in June 2018.
18. (1) 9. The member must ensure that the container in which the drug is dispensed is marked with, i. an identification number, if applicable, ii. the member s name and title, iii. the name, address and telephone number of the place from which the drug is dispensed, iv. the identification of the drug as to its name, its strength (where applicable) and, if available, its manufacturer, v. the quantity of the drug dispensed, vi. the date the drug is dispensed, vii. the expiry date of the drug, if applicable, viii. the name of the patient for whom the drug is dispensed, and ix. the directions for use. 18. (1) 10. The member must retain a copy of the information set out under paragraph 9 on the container in which the drug was dispensed in the patient s health record, along with the information 18. (12) 96. The member must ensure that the container in which the drug is dispensed is marked with, i. an identification number, if applicable, ii. the member s name and title, the prescriber s name and title iii. the name, address and telephone number of the place from which the drug is dispensed, iv. the identification of the drug as to its name, its strength (where applicable) and, if available, its manufacturer, v. the quantity of the drug dispensed, vi. the date the drug is dispensed, vii. the expiry date of the drug, if applicable, viii. the name of the patient for whom the drug is dispensed, and ix. the directions for use. 18. (12) 107 The member must retain a copy of the information set out under paragraph 9 on the container in which the drug was dispensed in the patient s health record, along with the information Currently this regulation only applies to NPs. With the revision to 18(1) described above, this labelling requirement will apply to any nurse (RPN, RN, NP) when dispensing medication. Sub-paragraph ii is changed so that nurses include the prescriber s name on the label. If a nurse is dispensing a medication s/he has also prescribed, the nurse includes her/his own name. This regulation reduces risk that patients (or family members) will confuse / misuse their medication, it also promotes opportunities for patient education. This regulation promotes safety in the event of a medication recall, by enabling the identification of patients who received recalled medications. This labelling requirement is consistent with the expectation of other health professionals who dispense medication. Council reviewed these dispensing standards (among others) in June 2018 Currently this regulation only applies to NPs. With the revision to 18(1) described above, this documentation requirement will apply to any nurse (RPN, RN, NP) when dispensing medication. The
provided by the patient in response to the inquiries under paragraph 5. provided by the patient in response to the inquiries under paragraph 5. reference to paragraph 5 is removed because the proposed revisions remove paragraph 5 from subsection 18 (1) see revisions at 18 (1) 5). It is currently an expectation of any nurse (RPN, RN, NP) to document when dispensing medication. The regulation requires that nurses document specific information about the medications they dispense. 18. (2) A registered nurse in the extended class shall not describe himself or herself orally or in writing as a person who is authorized to dispense a drug unless he or she sets out in writing or orally the inquiries that must be made by the member before dispensing a drug to a patient under paragraph 5 of subsection (1). Not applicable 20. For the purposes of subsection paragraph 6 of 5.1 (1) of the Act, a 18. (2) A registered nurse in the extended class shall not describe himself or herself orally or in writing as a person who is authorized to dispense a drug unless he or she sets out in writing or orally the inquiries that must be made by the member before dispensing a drug to a patient under paragraph 5 of subsection 20(1) A member who is a registered nurse or a registered practical nurse may administer a drug set out in Schedule 4 or a drug from within a category of drugs set out in Schedule 4 by injection or inhalation if the procedure is pursuant to a prescription issued by a registered nurse in the General class who is authorized to prescribe the drug 20(2) For the purposes of subsection paragraph 6 of 5.1 (1) of the Act, A Council reviewed these dispensing standards (among others) in June 2018. If paragraph 5 is removed (see revisions at 18 (1) 5), this regulation is no longer relevant. 20(1) Permits an RN or RPN to administer by injection/inhalation a medication that is prescribed by an RN. Council supported this policy in March 2018. This provision allows an RN, who is authorized to prescribe, to also administer a medication s/he has prescribed. Council supported this policy in December 2017 Subsection 20(2) paragraphs (a) and (b) are standards of practice for
member may only administer a substance member may only administer a substance by injection or inhalation if, by injection or inhalation if, (a) he or she has a nurse-patient relationship with the patient for whom the administration of a substance by injection or inhalation is performed; and (b) the procedure is performed only for therapeutic purposes. (a) he or she the member has a nursepatient relationship with the patient for whom the administration of a substance by injection or inhalation is performed; and (b) the procedure is performed only for therapeutic purposes. administering substances by injection/inhalation. Although these are currently expected of any nurse, this section of the regulation only applies to NPs. It is proposed to make this provision applicable to all nurses to avoid confusion, or the perception that we have inconsistent requirements for nurse performing this controlled act. Therapeutic purpose is defined broadly and includes medication used for any patient health care need, including treatment, disease prevention, health promotion, symptom management or lifestyle/choice. 35. (1) Subject to this Part, and to the terms, conditions and limitations placed on his or her certificate of registration, a registered nurse in the General or Emergency Assignment class or registered practical nurse in the General or Emergency Assignment class who is authorized to perform a controlled act set out in section 4 of the Act may delegate that controlled act. 35. (2) Despite subsection (1), a member mentioned in that subsection may not delegate the controlled act of treating, by means of psychotherapy technique delivered through a therapeutic 35. (1) Subject to this Part, and to the terms, conditions and limitations placed on his or her certificate of registration, a registered nurse in the General or Emergency Assignment class or registered practical nurse in the General or Emergency Assignment class who is authorized to perform a controlled act set out in section 4 or 4.1 of the Act may delegate that controlled act. No change Reference to 4.1 is added. This is a new section in the Nursing Act, 1991 that sets out the controlled acts that an RN is authorized to perform.
relationship, an individual s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual s judgment, insight, behaviour, communication or social functioning. 35. (3) Despite subsection (1), a member mentioned in that subsection may not delegate the controlled act of dispensing a drug. Not applicable (new section) No change 35. (4) Despite subsection (1), a registered nurse in the General class may not delegate the controlled acts of prescribing a drug or communicating to a patient or to his or her representative a diagnosis made by the member where the purpose of that communication is for prescribing a drug as authorized under paragraph 5 of section 4.1 of the Act. All nurses (RPN, RN, NP) are currently prohibited from delegating the controlled act of dispensing medication. RNs will be prohibited from delegating the new controlled acts: prescribing and communicating a diagnosis. For clarity, a delegation is the not the same as an order. The restriction on delegation will not prevent an RN from prescribing or ordering a drug in Schedule 4. Council supported this policy in March 2018. Not applicable (new) SCHEDULE 4 INDIVIDUAL DRUGS AND CATEGORIES OF DRUGS THAT MAY BE PRESCRIBED Vaccines for prevention of bacterial and viral disease Hormonal contraceptives for systemic use Intravaginal contraceptives The Nursing Act, 1991 requires the medications that RNs prescribe to be designated in the regulation. The proposed regulation includes a combination of medication categories and individual medications. Council established the initial areas of focus for RN prescribing in September 2017, which included: Immunization Contraception
Aminoquinolines for malaria prevention Biguanides for malaria prevention Methanolquinolines for malaria prevention Anti-bacterials for systemic use for malaria prevention or traveller s diarrhea Corticosteroids, plain for topical use Antibiotics for topical use Metronidazole for topical use Anesthetics for topical use Travel health Topical wound care (topical means the medication is applied to an area of the body) Smoking cessation These areas are consistent with evidence from other jurisdictions that enable RN prescribing. They were considered a suitable starting point given government parameters that apply to RN prescribing, including: RNs are not authorized to order lab or diagnostic tests, they are not authorized to prescribe for hospital patients, and this change in scope of practice is meant address people s noncomplex health care needs. Medicated dressings Bupropion for smoking cessation Varenicline Epinephrine for anaphylaxis Any drug or substance that may lawfully be purchased or acquired without a prescription and is available for selfselection in a pharmacy or retail outlet In September 2018, Council added the category of over-the-counter medication. This addition is in keeping with the objective of improving timely access to care, maintains focus on lower risk medications / non-complex needs and responds to challenges identified by employers in providing patients with timely access to these medications under current processes. Unless otherwise stated, RNs would be permitted to prescribe any medication included within a drug category. In some cases there are parameters placed on the routes and the purposes of prescribing. These are summarized in greater detail below.
Vaccines RNs would be permitted to prescribe any bacterial, viral, or combined bacterial/viral vaccine Contraceptives RNs would be permitted to prescribe any contraceptive for systemic use (which includes any route of administration) and topical contraceptive for intravaginal use. The regulation does not permit RNs to prescribe intrauterine devices. Antimalarials RNs would be permitted to prescribe any aminoquinoline, biguanide, or methanolquinoline for the purpose of malaria prevention. Anti-bacterials for systemic use RNs would be permitted to prescribe doxycycline for malaria prevention, and any antibacterial for traveller s diarrhea. Antibiotics for topical use RNs would be permitted to prescribe any antibiotic for topical use. Corticosteroids, plain for topical use RNs would be permitted to prescribe any corticosteroid for topical use. Anesthetics for topical use RNs would be permitted to prescribe any anesthetic that is applied to an area of the body. Medicated dressings RNs would be permitted to prescribe dressings that
include medicinal ingredients. Dressing that do not include medication, do not need to be identified in the regulation. Over-the-counter medication RNs would be permitted to prescribe any medication that is available over-the-counter and available for self-selection in a pharmacy or retail outlet. These are medications that the public can obtain without any health professional interaction. In some cases, people do need prescriptions for these medications; for example, any medication administered to people living in Retirement Homes and Long-Term- Care Homes must be prescribed by an authorized health professional. In addition to the above medication categories, RNs would be permitted to prescribe the following individual medications in keeping with the parameters identified (where applicable): Metronidazole for topical use Bupropion for smoking cessation Varenicline Epinephrine for anaphylaxis.