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Comment on proposed RN prescribing and other regulation changes

CNO is proposing regulation changes that would permit RNs who successfully complete education to prescribe certain medications and communicate diagnoses if they are prescribing medications to treat that diagnosis. The proposed regulation will also affect nursing practice related to dispensing and administering medication.

If you would like to submit feedback about any of the proposed changes, please read the details about the proposed changes below and complete this survey. (Consultation on the proposed changes is now closed. Thank you for your feedback.)

In March 2019, Council will review your feedback before it makes a final decision about submitting the new regulation to the government for consideration. If Council approves, the next step will be government approval, which is required for the regulation to take effect. CNO will work closely with the Ministry of Health and Long Term care to promote transparent communication about when the regulation will take effect so that stakeholders can prepare for the change.

Background

In May 2017, the Ontario government changed the Nursing Act to permit RNs to prescribe medication and communicate a diagnosis for the purpose of prescribing. The changes were made to improve access to care by allowing RNs to treat non-complex health conditions. CNO’s vision is that RN prescribing will be safe for the people of Ontario.

CNO has been working towards developing the framework that will enable this change in RNs scope of practice. The next step in this work is the proposed regulation changes for which we are now seeking feedback. 

Considerations

Please keep the following in mind when giving your feedback on the proposed regulation:

  1. We grouped the proposed regulation changes that require your feedback under these three areas:

RN prescribing and communicating diagnoses
Rationale: Earlier in the year, Council approved that RN prescribing will cover the following areas: immunization, contraception, travel health (prevention), topical wound care, over-the-counter medications. NOTE: Government laws do not permit RNs to order lab or diagnostic tests.

Dispensing medications

Rationale: Currently, all nurses (RN, RPN, NP) are permitted to dispense medications but the provisions in the regulation apply only to NPs. When nurses apply different standards when performing the same controlled act, it undermines confidence. 

Dispensing medication is an activity that can cause harm to the public. CNO wants to ensure that all nurses are practising to the same standard and that those standards are targeting risk of harm to patients: no more, no less. 

The proposed regulation would:

  • make RNs and RPNs accountable to new requirements, such as labelling and documenting specific information when dispensing medication.
  • remove some of the conditions that current apply only to NPs. These current conditions do not directly address risk of harm associated with dispensing medication and may unintentionally restrict a patient’s access and choice of provider.
  • allow RNs who are authorized to prescribe to provide an order for an RN or RPN to dispense medication. Currently, RNs and RPNs require an order from another health professional (such as NP or physician) to dispense medication.

Administering Substances

Rationale: Currently, all nurses (RN, RPN, NP) are permitted to administer substances by injection or inhalation but the provisions in the regulation only apply to NPs. 

The proposed regulations would:

  • make RNs and RPNs accountable to the same requirements, which already apply under College standards.
  • allow RNs who are authorized to prescribe to provide an order for an RN or RPN to administer medication. Currently, RNs and RPNs require an order from another health professional (such as NP or physician) to administer medication by injection or inhalation.
  1. The Nursing Act requires CNO to specify in the regulation the drugs or drug categories that RNs can prescribe. Proposed medications for RN prescribing are included in the draft regulation for your feedback
  2. Only RNs who complete CNO-approved education will be permitted to prescribe medication. The education will be developed and approved in the future.
  3. RNs who work in hospitals will not be able to prescribe medication due to restrictions under the Public Hospitals Act. RN prescribing would be permitted in other sectors, such as community, long-term-care and retirement homes.

How to give your feedback 

  1. Review the chart showing the proposed regulation changes and complete this online survey to provide your feedback, or send an email to regulations@cnomail.org.  (Consultation on the proposed changes is now closed. Thank you for your feedback.)
  2. The following documents are for your reference only. They will help to give you a comprehensive picture of the supports that will be in place for RN prescribing as you prepare to give your feedback on the proposed regulation. You are not being asked to provide feedback on these draft documents.

Frequently asked questions

1. What is the draft drug schedule based on?

CNO’s Council approved the following six areas as a starting point for future RN prescribing in Ontario:

  • Immunization
  • Contraception
  • Travel health (prophylaxis)
  • Topical wound care
  • Smoking cessation
  • Over-the-counter medication

Council based its decision on multiple factors, including:

  • evidence from other jurisdictions that have implemented RN prescribing
  • consultation findings from Ontario stakeholders (for example, employers)
  • government direction that this change in scope of practice is meant to enable RNs to manage “non-complex” patient care needs
  • current legislative parameters, specifically that government laws do not permit RNs to order diagnostic and lab tests

The Nursing Act requires that we specify in regulation the drugs that RNs are permitted to prescribe; we may specify individual drugs or drug categories. The proposed drug schedule is a combination of individual drugs and drug categories, which are based on the classification system set out by the World Health Organization (https://www.whocc.no/atc_ddd_index/)

2. Why is CNO proposing a list of drugs?

CNO did not propose a “drug list” model for RN prescribing, it was a government decision. CNO must comply with government law, including the Nursing Act, 1991, which provides the framework for RN prescribing. The Nursing Act clearly requires CNO to specify in regulation the drugs that RNs may prescribe.

We have some flexibility to name each drug (individually) in the regulation, or to name categories of drugs.

3. How did CNO decide on the medications included in the proposed regulation?

We are accountable for developing and implementing a regulation that will support competent and safe RN prescribing. As mentioned in question 1 above, the decision about a starting point for RN prescribing in the six defined areas was informed by:

  • Evidence from around the world, including the UK, New Zealand and elsewhere
  • Input from RNs and employers about potential practice areas (in surveys and consultations we completed in 2017 and 2018)
  • Government direction that we focus on “non-complex” patient care needs
  • Government restrictions that prevent RNs from ordering labs and diagnostics

CNO intends to work with RNs, employers and other stakeholders to evaluate this first phase to determine next steps in RN prescribing.

4. Does the proposed regulation support “independent” prescribing?

As regulated health professionals, all nurses are accountable for their own practice, which is what makes a health professional independent. RNs who prescribe will be solely accountable for their prescribing decisions and for complying with CNO standards. For more information about the accountabilities that will apply to an RN who is authorized to prescribe, please see the draft practice standard.

5. The draft regulation says that nurses can only prescribe, dispense and administer medication for “therapeutic purposes”. Does this mean their practice is limited to the treatment of health conditions, diseases and disorders?

The term “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. This requirement is already in place for NPs, the draft regulation ensures that nurses are accountable to the same standards for public protection when performing controlled acts.

6. The draft regulation requires nurses to include an “identification number if applicable” and “the drug manufacturer’s name if available”. What are these, and why are they necessary to protect the public?

An identification number and manufacturer name are ways that a medication can be identified in the event of safety concerns, such as a recall. An identification number may be in place where employers have tracking systems for medications used in the practice setting. This provides a way for health professionals to identify which patients received which medication. The manufacturer’s name provides a way for patients to identify that a medication they received is part of a recall.

These same labelling requirements are already in place for NPs, the draft regulation ensures that nurses are accountable to the same standards for public protection when dispensing medication.

7. Can CNO enable RNs to prescribe lab and diagnostic tests?

No, this is a government decision.

8. Can CNO enable RNs to prescribe medication for hospital patients?

No, this is a government decision.

9. Will RNs be required to complete education before being authorized to prescribe medication?  

Yes, RNs will be required to complete CNO-approved education to become authorized to prescribe medication. This education is not yet developed. For more information, please see the draft competencies that will need to be included in curriculum to support safe RN prescribing.

 

 

Page last reviewed February 19, 2019