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Nurse Practitioners

Nurse Practitioners (NPs), also known as Registered Nurses in the extended class, are registered nurses who have met additional education, experience and exam requirements set by the College. They are authorized to diagnose, order and interpret diagnostic tests, and prescribe medication and other treatment.  

NPs are accountable to the Nurse Practitioner practice standard in addition to the other practice standards and guidelines all nurses must follow.

Illegal prescribing: What you need to know

The College has received reports from Ontario’s Narcotics Monitoring System showing that some NPs are prescribing controlled substances, which is illegal. Use this information to reflect on your practice and identify what changes you may need to make.

Read more

 

Diagnostic Test List

NPs are authorized to order the following diagnostic tests: 

  •  X-rays of the chest, ribs, arm (includes shoulder and elbow), wrist, hand, leg (includes hip and knee), ankle and foot, as well as mammography –– includes specific views (e.g., coned)
  • Diagnostic ultrasound of the abdomen, pelvis and breast –– includes specific views (e.g., of a specific organ), techniques (e.g., transvaginal) or indications (e.g., pregnancy) within these anatomical regions
  • Electrocardiograms in non-urgent, non-acute circumstances
  • Spirometry

Laboratory Tests

Regulations under the Laboratory and Specimen Collection Centre Licensing Act allow NPs to order laboratory tests as appropriate for client care.

NPs are expected to apply the practice expectations for public protection set out in the Nurse Practitioner practice standard.

Medication

The Nursing Act, 1991 allows NPs to prescribe most medication as appropriate for client care. NPs are not authorized to prescribe controlled substances. A controlled substance is one that is included in Schedule I, II, III, IV or V of the Controlled Drugs and Substances Act. (CDSA)

To check whether a medication is a controlled substance, search the CDSA Schedules or Health Canada’s Drug Product Database.

When prescribing medication, NPs are expected to apply the practice expectations for public protection set out in the Nurse Practitioner practice standard.

 

Still have questions? Call our Practice Line at 416 928-0900 ext. 6397 (toll-free Canada-wide 1 800 387-5526). You can also email your question at any time to ppd@cnomail.org.

This section provides practice resources for NPs. The information is intended to complement the Nurse Practitioner practice standard. The College is not responsible for information provided by external organizations.

 

Ordering Laboratory and Diagnostic Tests

OHIP Billing

When ordering tests, NPs must include their OHIP billing number on the requisition. This number authorizes the laboratory or diagnostic facility to bill the Ontario Health Insurance Plan (OHIP) for the tests. For more information on how to obtain an OHIP billing number, contact the Ministry at 1 800 268-1154 (416 314-5518 in Toronto) or visit OHIP’s website to download the Application for OHIP Billing Number for Health Professionals (No. 3384-83).

Laboratory Tests

Many quality issues that result in a laboratory's rejection of a specimen can be resolved through upfront communication between the provider ordering the test and the local laboratory.

NPs who have questions about laboratory policies and procedures for ordering tests and collecting, labeling, storing and transporting samples are encouraged to consult the laboratory prior to ordering the test to mitigate the risk of specimen rejection. For further information, refer to the Ontario Association of Medical Laboratories' Guidelines for the Rejection of Specimens.

Applying Forms of Energy

NPs are not authorized to apply a form of energy until the Ontario government creates a regulation to enable this practice. In the meantime, NPs can apply forms of energy if delegated to do so by an individual authorized under the Regulated Health Professions Act, 1991. More information about forms of energy in the context of nursing practice is available here.

Prescribing and Ontario Public Drug Programs

Ontario Drug Benefit (ODB) Program

The Ontario Drug Benefit Program (ODB) provides drug benefits for eligible Ontarians. Prescriptions written by NPs and dispensed in Ontario are ODB-eligible. NPs must include their College registration number on prescriptions.

NPs who prescribe medications to ODB-eligible clients must have an OHIP billing number. This number is not required on the prescription, it is used by the Ministry when adjudicating claims. For more information, or to obtain a billing number, contact the Ministry at 1 800 268-1154 (416 314-5518 in Toronto) or visit OHIP's website to download the Application for OHIP Billing Number for Health Professionals

The ODB formulary is regularly updated and published. Information about ODB and other Ontario public drug programs is available from the Ministry of Health and Long-Term Care.

Limited Use Drugs

NPs may prescribe a limited use drug if the client satisfies ODB-listed limited use criteria, and the NP writes the limited use code on the prescription. Limited use prescriptions must include a Limited Use/Nutrition Product Form that indicates the reason for use. More information about limited use drugs is available on the Ministry’s website.

Exceptional Access Program (EAP)

ODB cannot accept an NP prescription under the EAP because the Ontario Drug Benefit Act limits this authority to physicians only. However, ODB will reimburse clients when an NP renews the prescription if a physician provided the initial prescription under the EAP. More information about the EAP is available on the Ministry's website. 

Lost or Stolen Prescriptions

To prevent prescription fraud, NPs are expected to adopt strategies such as reducing the risk of lost or stolen blank prescriptions. In the event of lost or stolen prescriptions, work with the employer to manage risk and determine whether a report to police is appropriate and in keeping with Ontario’s health privacy law. Inform Ontario Public Drug Programs of lost or stolen prescriptions by sending an email to publicdrugprgrms.moh@ontario.ca or calling 1-866-811-9893 – they will notify pharmacies about missing prescriptions to reduce the potential for fraud.

Special Access Program

Health Canada’s Special Access Program (SAP) allows practitioners to request access to drugs that are unavailable for sale in Canada. This access is limited to clients with serious or life-threatening conditions on a compassionate or emergency basis, when conventional therapies have failed, are unsuitable, or are unavailable. NPs may request access to medications that they are legally authorized to prescribe through the SAP. More information about the SAP, and requirements that practitioners must meet, is available on Health Canada’s website.

Facilitating Access to Personal Supports

Assistive Devices Program (ADP)

The ADP helps eligible Ontarians with long-term physical disabilities access and pay for personalized assistive devices. The Ministry accepts NP authorization forms for several devices and supplies. For more information on the type of devices and the circumstances in which NPs can complete authorization forms, call the Ministry at 1 800 268-6021 (416-327-8804 in Toronto) or visit the Ministry website.

Ontario Disability Support Program (ODSP)

ODSP provides income and employment support to eligible Ontarians. When assessing an individual’s eligibility for income support, ODSP accepts an NP’s assessment of a client’s physical or mental impairment and the expected duration of that impairment. As well, NPs can complete an application for a special diet allowance for eligible recipients. For more information about ODSP, visit the Ministry's website.

Workplace Safety and Insurance Board (WSIB)

The Workplace Safety and Insurance Board (WSIB) recognizes NPs as service providers. To bill WSIB, NPs must obtain a WSIB provider identification number, available by calling WSIB at 416 344-4526 or 1 800 569-7919, or by completing this online form (No. 189OA)

Hospital Practice

Hospital Privileges

NPs who are employees of a hospital are authorized to order diagnostics and treatments for hospital patients (in-patients and out-patients). NPs who are not hospital employees may apply to the hospital for these privileges; however it is up to the discretion of the hospital whether they will grant privileges.

Regulation 965 under the Public Hospitals Act specifies that the hospital’s Medical Advisory Committee (MAC) can make recommendations to the hospital board about granting privileges to NPs who are not hospital employees. The hospital’s MAC is also responsible for the overall supervision and quality of the practice of NPs who have been granted hospital privileges. To apply for hospital privileges, contact the individual hospital.

Admitting and Discharging Clients

NPs are authorized to admit and discharge hospital patients. The process for an NP to admit and discharge clients is up to the discretion of the hospital. An NP should always consult with the facility for further information on its policies.

Public Health Reporting

Under the Health Protection and Promotion Act, NPs have a duty to report certain diseases to the medical officer of health in their local public health unit, if they suspect or know that a person has or may be infected with a communicable disease.

The Ministry of Health has a list of the local public health units in Ontario and their locations.

For a list of reportable diseases and infectious agents, as well as instructions on reporting, contact your local public health unit.

Reporting to the local public health unit

In facilities (such as, hospitals and long-term-care homes), it is the employer's responsibility to report diseases or infectious agents. If you work in a facility, consult the applicable facility policies and procedures on how reporting will take place.

In addition, NPs have a duty to report when a client refuses or neglects treatment for a communicable disease. A report containing the client’s name and address should be made to the medical officer of health in their local public health units.

If an NP certifies death where a communicable disease was a cause or contributing factor of the client’s death, this information must be reported to the local public health unit.  For information about the circumstances in which NPs are authorized to certify death, see Issuing Medical Certificates of Death (below).

An NP who has information about any animal bite or other animal to human contact that may result in rabies must report the information to the local medical officer of health as soon as possible.

Issuing Medical Certificates of Death

The provincial Vital Statistics Act gives NPs the authority to complete a Medical Certificate of Death (Form 16) in specific circumstances. NPs can complete a Medical Certificate of Death of the deceased when:

  • the NP had primary responsibility for the deceased’s care
  • the death was expected
  • a documented medical diagnosis of a terminal disease had been made by a medical practitioner
  • there was a predictable pattern of decline, and
  • no unexpected events or complications arose.

An NP had primary responsibility for the deceased’s care when she or he had an established therapeutic nurse-client relationship with the client and provided care to the client either independently or as a member of a team of health care providers. NPs should not sign the Medical Certificate of Death for clients they did not care for, did not have contact with or did not know.

When NPs are unsure if the circumstances surrounding the death of the client were unexpected, they must consult with a physician.

Before signing a Medical Certificate of Death, NPs must read and follow the instructions in the Handbook on Medical Certification of Death. The expectations outlined in the handbook apply in all circumstances, including deaths that have occurred in hospital.

If the death has occurred in a hospital and is a coroner’s case, and the coroner does not provide the NP with a copy of the medical certificate of death, the NP is required to complete the Certificate of Death Form (see Regulation 965 of the Public Hospitals Act.)

Providing Immunizations

Immunization of School Pupils

Under the Immunization of School Pupils Act, NPs are authorized to complete a statement that exempts a child from a childhood immunization required for school attendance in Ontario. The conditions under which an exemption may be provided are:

  1. the immunization may be detrimental to the health of the client (i.e., the child is known to be allergic to a substance in the vaccine), or
  2. the immunization is unnecessary because the client is already immune (i.e., there is laboratory evidence of immunity).

Immunization reactions

Under the Health Protection and Promotion Act, NPs have a duty to report to the medical officer of health in their local public health unit, any of the following immunization reactions:

a)      Persistent crying or screaming, anaphylaxis or anaphylactic shock within 48 hours after immunization

b)      Shock-like collapse, high fever or convulsions within 3 days after immunization

c)      Arthritis within 42 days of immunization

d)     Generalized urticaria, residual seizure disorder, encephalopathy or any other significant occurrence within 15 days of immunization

e)      Death occurring at any time or death following any of the above.

NPs must make the report within 7 days of determining that a client has, or may have, experienced any of the above reactions.

In addition, when health care workers are obtaining consent for immunizations, they must provide education to clients about the importance of immediately reporting to a physician or NP, any reaction that might be a reportable event.

Completing Transportation-Related Forms

Parking Permits       

NPs can complete the Application for Accessible Parking Permit form (SRLV-129 07-08) for clients. The form is available on the Ministry of Transportation website and at any ServiceOntario driver and vehicle licence issuing office.

Commercial Licence Medical Report

NPs can complete the Commercial Licence Medical Report form (i.e., drivers’ physical). For further information, visit the Medical Review Section (Commercial Drivers) of the Ministry of Transportation website.

Fitness to Drive Medical Reports

The Ministry of Transportation has a series of “condition-specific” medical forms that it provides to people who have been reported as having a medical condition that may make it dangerous for them to drive.

The initial medical condition report about a person’s fitness to drive is usually completed by a physician. NPs' clients may ask them to complete a follow-up condition-specific assessment and form. There are several forms for conditions such as substance use disorders, sleep disorders, cognitive impairment and so on. For more information, visit the Medical Review Section of the Ministry of Transportation website.

Still have questions? Call our Practice Line at 416 928-0900 ext. 6397 (toll-free Canada-wide 1 800 387-5526). You can also email your question at any time to ppd@cnomail.org.

Maintaining Membership in the Extended Class

1. Is there a requirement for me to practise as an NP in a clinical role in Ontario to maintain my Certificate of Registration as an NP?

Yes. Under the Registration Regulation, NPs must maintain clinical NP practice in Ontario to remain registered in the Extended Class. This clinical practice must include:

  • direct interaction with the client population(s) consistent with each specialty certificate that the NP holds and
  • the use of advanced nursing knowledge and decision-making skill in health assessment, diagnosis and therapeutics in the treatment of those clients.

Each year, NPs will be asked to declare if they have practised as described above in Ontario within the previous three years. NPs who do not meet this requirement will not be eligible to remain registered in the Extended Class.

2. What is the declaration of practice? When do I make this declaration?

While completing the Annual Membership Renewal form each year, and at any other time upon request by the College, NPs will be required to declare whether they practised as NPs, as described in the first question above, in Ontario within the previous three years. NPs who hold multiple specialty certificates in the Extended Class will be required to make this declaration for each specialty certificate they hold. Upon request by the College, members must provide evidence to support their declaration.

3. a) I am an NP-Primary Health Care (PHC) working in a Long-Term Care home. Am I required to practice with clients in all age groups to maintain my current certificate of registration?

No. Each NP specialty certificate represents a broad client population and a wide age range. The client population for the PHC specialty is “family all ages.” Therefore, you can meet the NP declaration of practice requirement by practising, as described in the first question above, with clients in any or all age groups within your specialty. As always, you are expected to meet the practice expectations for public protection described in the Nurse Practitioner practice standard.

b) I know I must fulfil the College's QA (Quality Assurance) obligations to maintain my certificate of registration. How will my practice within the NP-PHC specialty be assessed when I'm selected for practice assessment in the QA program?

To protect the public, the QA program requires each NP to demonstrate competence for the specialty certificate in which she or he is registered. This is because NPs may work in a wide variety of practice settings and a wide range of clients are covered by each specialty certificate. In addition, Ontario law requires Colleges to assess entry-to-practice competencies through their quality assurance processes. 
When you are selected to participate in the College’s QA practice assessment, you will be required to demonstrate the core competencies and the use of advanced knowledge and decision-making skill in health assessment, diagnosis and therapeutics with a primary health care "family all ages" population.

4. The clinical practice requirement doesn’t recognize that NPs contribute to the health system in many ways beyond the provision of direct client care. Why is the College requiring NPs to engage in direct clinical practice with clients?

The College recognizes there are numerous ways in which nurses provide positive contributions to client care and the health system, and that nursing practice does not always involve direct interaction with clients. Examples include policy development, administration, research and education. The College appropriately and safely regulates these aspects of nursing practice through the General Class.

The Extended Class exists to authorize RNs who have met specific requirements to perform certain controlled acts (e.g., communicating diagnoses, prescribing medication) that are directly linked to clinical practice. To protect the public, NPs are expected to demonstrate and maintain competence to practise in a clinical NP role. This has been an expectation under the Nurse Practitioner practice standard since October 2011. Adding this requirement to the Registration Regulation reinforces the expectations and standards, and is consistent with those of other nursing jurisdictions across Canada. 

5. What happens if I have not practised in a clinical NP role in the previous three years in Ontario?

If you have not practised as an NP as described in the first question in the previous three years in Ontario, but have practised nursing in Ontario during that time, then your Extended Class certificate will be revoked and replaced with a General Class certificate. If you have not practised nursing in Ontario at all in the previous three years, then you must either register in the Non-Practising Class or resign from the College.

6. Do NPs have to practise for a minimum number of hours to meet the NP practice requirement?

The College does not specify the number of hours that NPs must practise in Ontario within the three-year timeframe. The amount of practice needed to maintain NP competence in the areas of health assessment, diagnosis and therapeutics in the treatment of clients will vary for individual NPs based on their experience, knowledge and skill level. It is up to each NP to determine how much practice is required to maintain that level of competence. NPs are also required to meet continuing competence requirements related to application of practice standards and related NP competencies.

7. Does the College provide a list of nursing positions that satisfy the NP practice requirement?

No. Nurse Practitioners work in roles that involve various dimensions of nursing practice, including clinical and nonclinical components. Therefore, what must be determined is whether an individual NP meets the requirement as outlined in the first question, irrespective of her or his position. NPs are expected to reflect on their nursing practice and determine whether it satisfies the practice requirement.

8. I am an NP and a faculty member in an approved NP university education program. Does my position meet the evidence of practice requirement?

The College does not determine whether a position fits the requirement; it is whether an individual NP meets the requirement. You are expected to reflect on your role as a faculty member and determine whether you satisfy the practice requirement for NPs as described in the first question.

9. Does volunteering in an NP role meet the NP practice requirement?

Providing nursing services in a volunteer capacity meets the requirement if it is consistent with the definition of NP practice as described in the first question. Keep in mind that you will have to provide evidence to support your declaration if the College requests it.  

10. I work in another jurisdiction. My NP practice allows me to maintain competence in the areas of health assessment, diagnosis and therapeutics. What is the rationale for not recognizing my NP practice in another jurisdiction?

The College’s mandate is to regulate nursing practice in Ontario. It does not have jurisdiction to govern a member’s practice in any other jurisdiction. If you are not practising in Ontario, but you wish to remain a member of the College, then you may register in the Non-Practising Class. If you join that class, then it will be clear on the public register that you are a member of the College but not currently practising nursing in Ontario. This ensures accurate and transparent information about you, as a nurse in Ontario, to the public. If you wish to return to NP practice in Ontario in the future, you will need to apply to have your Extended Class certificate reinstated.

11. I am registered as an NP and hold both Adult and Paediatrics specialty certificates. I work in a role that involves providing NP health care services to an adult population. Do I meet the evidence of NP practice requirement?

You must demonstrate practice, as described in the first question, with a client population that is relevant to each specialty in which you are registered. In this case, your Paediatrics specialty certificate will be revoked if you do not practise with paediatric clients in accordance with the practice requirement for NPs as described in the first question. Assuming your practice with adult clients is consistent with the NP practice requirement, your NP registration with the Adult specialty certificate will not be affected.

Reinstating NP Registration

If I receive a General Class certificate because I did not meet the practice requirement for NPs, what will I need to do if I want to resume practise as an NP in Ontario?

You will need to apply to reinstate your NP certificate and the specialty certificate that you previously held. To reinstate, you will have to demonstrate evidence of NP practice within the previous three years. That practice must be clinical and include:

  • direct interaction with the client population(s) consistent with each specialty certificate you previously held and wish to have reinstated and
  • the use of advanced nursing knowledge and decision-making skill in health assessment, diagnosis and therapeutics in the treatment of those clients.

If you have been practising as an NP in another jurisdiction, then your practice there will be assessed to determine whether it meets the above description. You may also be expected to meet other reinstatement requirements, such as successful completion of the jurisprudence exam.

Acquiring NP Registration

Do graduates of approved NP programs have to meet the practice requirements to become registered as NPs?

Yes. Evidence of practice in the NP role is a non-exemptible registration requirement. If you completed an approved NP program within the past three years, then you will satisfy the evidence of NP practice requirement.

If it has been more than three years since you completed an approved NP program, then you must demonstrate that you have practised within the past three years in a clinical NP role that included:

  • direct interaction with client population(s) consistent with each specialty certificate for which you are seeking registration and
  • the use of advanced nursing knowledge and decision-making skill in health assessment, diagnosis and therapeutics in the treatment of those clients.

If you have not practised accordingly, then you will be required to undergo an evaluation approved by the College’s Registration Committee to determine whether you meet the practice requirement. The evaluation may conclude that you meet the NP practice requirement for registration, or it may identify the need for you to complete further training, experience, examinations or assessments to meet the requirement.

I am an RN who is practising in Ontario and applying to register as an NP. Why do I have to successfully complete the jurisprudence exam if I am already practising nursing in Ontario?

The jurisprudence exam is a non-exemptible registration requirement for applicants. The exam assesses an applicant’s awareness and understanding of the legislative and regulatory framework (i.e., laws, regulations, by-laws, practice standards and guidelines) that governs the nursing profession specifically in Ontario.

For NP applicants, the jurisprudence exam includes questions applicable to all nurses in Ontario and questions that are unique to NP practice. While many NP applicants are already practising nursing in Ontario as RNs in the General Class and would likely be familiar with the concepts assessed on the jurisprudence exam, they must demonstrate that they have this knowledge by successfully completing the RN(EC) Jurisprudence Examination before they can register in the Extended Class. 

 

Still have questions? Call our Practice Line at 416 928-0900 ext. 6397 (toll-free Canada-wide 1 800 387-5526). You can also email your question at any time to ppd@cnomail.org.

General

I just received my NP Certificate of Registration. How do I sign my name?

You must sign as either Nurse Practitioner (NP) or Registered Nurse, Extended Class [RN(EC)]. You may also add your specialty certificate designation:

  1. NP-Adult
  2. NP-Paediatrics
  3. NP-Primary Health Care (NP-PHC)


No other variations of the NP title may be used.

I work in a clinic where the primary health care providers charge clients fees for services, such as completing forms or providing sick notes. Can I charge clients fees for these types of services?  

Most NPs are salaried employees. To reduce the risk of conflict of interest, ensure there are clear parameters about whether these services are offered during regular work hours and how the revenue generated from these fees will be managed. You should work with your employer to develop a clear workplace policy about charging clients fees. Policies should be consistent with the standards and regulations governing affected health professionals. Decisions should be made in the best interest of clients and the policy should address ethical considerations, including the process for clients who cannot afford to pay a fee.

Refer to the College’s Professional Misconduct document for information about nurses’ professional accountabilities when charging fees.

I am an NP employed at a primary health care clinic. I gave my employer notice and they will not recruit a new NP before I leave. What are my professional accountabilities in this situation? After I’ve left, can I follow-up on diagnostic tests that I have ordered?

When you are no longer employed at this clinic, you cannot access client health records, including diagnostic test results. You can only remain involved in the care of these clients if your employment is extended, or you are retained by the employer in some other way (e.g., contract), to provide health services to these clients.

You are accountable for working with the employer to facilitate continuity and transfer accountability of client care. This may include strategies such as: notifying clients and giving them information about how their health care needs will be met, prioritizing high-risk clients for appointments, and ensuring the employer is aware of pending diagnostic test or lab results.   

The employer is responsible for ensuring strategies are in place to meet client-care needs while they recruit your replacement. This may include making arrangements with other service providers, or using other strategies that fit the clients’ needs.

Ordering and performing tests

Can I perform point of care testing, such as rapid strep tests and urine dipstick analyses?

No. Health care professionals who perform laboratory tests for the purpose of diagnosing and treating their clients require an exemption under the Laboratory and Specimen Collection Centre Licensing Act. NPs are not exempt under this legislation. Therefore, you may perform point of care laboratory tests only with proper authorizing mechanisms (for example, a medical directive).

The College has recommended to government that this legislation be changed to exempt NPs and enable them to perform point of care laboratory tests, which are an essential part of NP practice. For more information, see Bill 179 FAQ.

I write orders such as requisitions for laboratory and diagnostic tests for clients when they are discharged from hospital. What is my accountability in following up with clients in this situation?

As the health professional who ordered the test, you are also accountable for following up, or ensuring there is a reliable system in place for appropriate follow-up. This means that you and the hospital should have a process for reviewing the results from the tests you have ordered and following up with clients.

You can facilitate the safe transfer of accountability by providing a timely discharge summary, including information about tests ordered. To promote continuity of care, you can make sure laboratory and diagnostic requisitions include a request to have test results sent to both yourself and the Primary Health Care provider.

You are accountable for communicating the following information with clients and documenting them:

  • the significance of the tests being ordered,
  • potential implications of not taking the test,
  • what type of follow-up to expect, and
  • how they will receive the test results.

You may also want to give a copy of the discharge summary to clients. The accountabilities when ordering tests are outlined in the Nurse Practitioner practice standard.

What is my accountability if a client does not undergo a test that I have ordered?

There is a shared accountability; ultimately, clients make their own decision about whether to undergo a test. You are accountable for ensuring clients have the necessary information to make an informed decision about taking the test. In addition, you are expected to ensure systems are in place to track that you have ordered the test. This enables you to follow up with the client if required. If you learn that your client has not taken the test, it provides you with an opportunity to explore the client’s reasons and engage in additional health teaching. You should document your follow up with the client, including any unsuccessful follow-up attempts if the client does not respond.

Can I apply ultrasound?

You cannot apply “diagnostic ultrasound”, which is a controlled act. The forms of energy that NPs are authorized to apply must be specified in regulation, which has not yet been drafted by the government. Until the necessary regulations are in place, you must continue to use delegation for applying forms of energy, such as diagnostic ultrasound.

The use of “procedural ultrasound”, which is not used to make a diagnosis, is not a controlled act. Therefore, you may use ultrasound to perform procedures, such as paracentesis or placement of a peripherally inserted central catheter. The practice expectations for public protection when performing procedures are described in the Nurse Practitioner practice standard.

Prescribing and administering medication

Why must I include my registration number on prescriptions?

The College requires that your registration number be included on prescriptions for authenticity. An NP’s registration number is a unique identifier and the most direct way for a pharmacist to verify that the prescription was authorized by a legitimate prescriber and to make direct contact with the NP to validate the prescription. The registration number is also used by insurers, such as the Ontario Drug Benefit program and others, to verify prescriptions when reimbursing clients or pharmacists directly.

Can I prescribe Tramadol?

Yes. An NP can prescribe Tramadol. The drug is an opiate analgesic but it is not a controlled substance under the Controlled Drugs and Substances Act.

At some point in the future, Health Canada may classify Tramadol as a controlled substance. If this happens, NPs will no longer be able to prescribe this medication. NPs are accountable for knowing the legislation that affects their practice and complying accordingly.

The College will update its website if this change occurs.

What are the requirements when prescribing Tramadol?

Tramadol is a monitored drug under the Ontario government’s Narcotics Safety and Awareness Act, 2010. NPs and other health professionals who prescribe or dispense monitored drugs must know and comply with specific legal requirements. For example, NPs must include a client identification number from a government-approved form of identification (e.g., Ontario Health Card) on the prescription for Tramadol. For more information about the legislative requirements, including a list of the acceptable forms of identification, visit the Ministry of Health and Long-Term Care’s website.

Like other opiates, Tramadol is subject to potential misuse, abuse, addiction or diversion. NPs are expected to consider this in their clinical decision-making to ensure safe prescribing. For example, NPs should assess clients for potential drug abuse behaviour and document their findings. The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain provides useful guidance.

As always, NPs must apply the practice expectations for public protection described in the Nurse Practitioner practice standard.

Controlled Substances

What are controlled substances and why are they restricted?
A controlled substance is one that is included in ScheduleI, II, III, IV or V of the federal Controlled Drugs and Substances Act. A wide variety of medications used in health care are controlled substances, including opiates, benzodiazepines, amphetamines, sedatives, anti-emetics and hormonal therapies, among others. Controlled substances are restricted because they present a high risk for potential misuse, abuse, addiction or diversion. 

Can I prescribe controlled substances?
No, it is illegal for NPs to prescribe controlled substances in Ontario. In 2012, the federal government created regulations under the Controlled Drugs and Substances Act to allow NPs to prescribe controlled substances; however, until the Ontario law (regulation 275/94 of the Nursing Act, 1991) is changed,  NPs in Ontario are prohibited from this practice. All nurses are accountable for knowing and complying with the laws that apply to their practice.

You may not always be aware that a medication you intend to prescribe is a controlled substance, so you must verify and if it is, refrain from prescribing it. Verify which medications are controlled substances by checking Schedule I, II, III, IV and V of the Controlled Drugs and Substances Act.

I’ve heard that federal law allows NPs to prescribe marijuana. Can I sign a medical document stating that my client is eligible for medical marijuana?

No. In Ontario, the Nursing Act, 1991 prohibits NPs from prescribing controlled substances so it is illegal for you to sign the document authorizing medical marijuana for your client. Federal law only allows NPs to prescribe controlled substances, such as marijuana, if the law in their province or territory allows it.

Will NPs be required to complete specific education before they gain the legal authority to prescribe controlled substances?
The College is still in the early stages of exploring an educational requirement. At its March 2014 meeting, the College’s Council supported that NPs may be required to complete specific education before they are authorized to prescribe controlled substances.
The College will communicate details, such as approved courses if applicable, in the future. 

Will this education eventually be included in entry-level education programs for NPs?
If the regulation authorizing NPs to prescribe controlled substances takes effect, entry-level NP education programs in Ontario will be expected to include education related to the competencies for safe, effective and ethical prescribing of controlled substances.  

What do I do if I determine that a client requires a prescription for a controlled substance?
NPs can expect to encounter clients requiring prescriptions for controlled substances, since many medications are controlled substances.  You should plan for this anticipated client care need by establishing strategies consistent with College standards and guidelines. You should also work with your employer to ensure you have access to resources for meeting client needs. In this case, the resource you need is physician availability. If the client needs a prescription for a controlled substance, the prescription must be filled out by a physician in a manner that is consistent with the physician's regulatory obligations.   

Can I create a prescription for a controlled substance for a physician to sign?
It is not acceptable to create a prescription that contains your contact information if another health professional signs the prescription. This includes prescriptions in written form (where the NP hand-writes the prescription, consults a physician and the physician signs the script) or in electronic form (where the NP uses the facility’s electronic medical record to generate the prescription, which is then printed and signed by the physician). The person who signs the prescription is considered the prescriber. Prescriptions are a form of communication about client care between a prescriber and a dispenser; therefore, they must be complete, accurate and clear. The prescription must include the prescriber's details (e.g., name, registration number) and contact information. "Mixing" your contact information with a physician’s signature causes confusion for pharmacists about who is prescribing the medication and creates the risk of error. For example, the pharmacist may enter your registration number along with the prescription into the provincial Narcotics Monitoring System. 

I assessed a client and determined that she needs treatment with a controlled substance. The physician I work with agreed with my findings and proposed a treatment plan. Can I complete this prescription based on the outcome of my consultation with the physician?

No. Consultation with a physician does not give you the legal authority to prescribe a medication. The authority to prescribe medication comes from the legislation. It is illegal for NPs in Ontario to prescribe controlled substances; therefore, in this case the physician should be asked to prescribe the controlled substance. Physicians have their own professional accountabilities, which may also require them to personally assess the client.

I am an NP with a clinical focus in pain management. Can I use a medical directive to provide opioid medications to clients?
No. Medical directives cannot be used to provide narcotics. Health Canada, the federal department responsible for administering the Controlled Drugs and Substances Act, does not allow medical directives to be used for controlled substances. A client-specific prescription from a physician is required for the client to receive these medications, and for any dose changes.

There used to be two benzodiazepines (Lorazepam and Diazepam) on the NP drug list for emergency purposes. Now that there is no drug list, can I prescribe these drugs?
No. These medications are governed by the federal Controlled Drugs and Substances Act and cannot be prescribed by NPs until Ontario regulations are amended to enable this practice.

Tylenol #1 can be dispensed at a pharmacy without a prescription. Does this mean that I can prescribe Tylenol #1?
No. NPs are not authorized to prescribe controlled substances, including codeine (a component of Tylenol #1). Under the Narcotic Control Regulations, pharmacists do not need a prescription to  dispense specific preparations containing codeine phosphate. This permission given to pharmacists is not applicable to NP prescribing authority. For further information about these preparations, refer to subsection 36 (1) of the Narcotic Control Regulations

Where can I find information about Ontario’s Narcotics Strategy, and the Narcotics Monitoring System?
Information about Ontario's Narcotics Strategy and the Narcotics Safety and Awareness Act, 2010 can be found on the Ministry of Health's website. As part of the Narcotics Strategy, the province has established the Narcotics Monitoring System(NMS) to monitor the prescribing and dispensing of controlled substances. Although its name implies the monitoring of narcotics, the NMS monitors all controlled substances as well as opioids that are not controlled substances (such as medications containing Tramadol). The main purpose of the NMS is to examine drug use patterns to inform harm reduction strategies and education initiatives, and improve prescribing and dispensing practices related to monitored drugs. If illegal activity or professional misconduct is suspected, the Ministry may report information from the NMS to law enforcement bodies and regulatory colleges. 

I’ve heard that the College has received NMS reports from the government. How has the College responded to these reports?  

The College has received NMS reports that showed a significant number of NPs were prescribing controlled substances. All reports that the College receives are assessed through a standardized process to determine the level of risk. Where risk is high, investigations may be necessary.

To address this issue, the College met with members to encourage an understanding of the law and the standards, with the goal of improving practice. (For more information view the  practice reflection videos.)
Through these meetings, the College learned that there may be confusion about whether an NP or a physician may prescribe controlled substances. Examples include physicians cosigning prescriptions written by NPs and NPs completing prescriptions after consulting a physician.

The College has had extensive communication with NPs and stakeholders such as pharmacists and employers. This communication has revealed some systems issues regarding prescribing of controlled substances. The College has encouraged NPs to address these issues collaboratively with their teams and employers.

Lastly, to alert NPs, educational articles were included in The Standard, direct emails were sent, information was posted on the College’s website and the issue was addressed at conference presentations.

Can I dispense medications that are controlled drugs and substances? 

Yes, you can dispense a controlled substance if it has been ordered by a physician or dentist with whom you work. The practice expectations for public protection when dispensing medication are described in the Nurse Practitioner practice standard.

Dispensing, selling and compounding medication

Can I dispense medications that are controlled drugs and substances?

Yes, you can dispense a controlled substance if it has been ordered by a physician or dentist with whom you work. The practice expectations for public protection when dispensing medication are described in the Nurse Practitioner practice standard.

I notice that I may be required to put an “identification number” on a medication that I dispense. What is the identification number?

The identification number is assigned to track medications from the point of procurement to the point they are provided to a client. The purpose of an identification number is to trace a medication back to the manufacturer. In the event of safety concerns (e.g., a medication recall), the identification number enables health professionals to follow up with clients appropriately.

You should consult your employer about whether this tracking system exists in your practice setting and how to obtain the identification number. If such a system does not exist, you should advocate for measures to ensure safe medication practices. If you are self-employed, you are expected to establish your own tracking system. The practice expectations for public protection when dispensing medication are described in the Nurse Practitioner practice standard.

Why is the drug manufacturer’s name required on the label of a medication I dispense? What if this information is not available to me?

Including the manufacturer’s name is another mechanism used for tracking medication. Depending on your practice setting, this information may not be readily available to you. For example, if you are dispensing medication from a supply that is stocked by a pharmacist, the medication may have been re-packaged, and therefore, while this information is available to the pharmacist, it is not available to you. If you do not have access to this information, then you are not required to include it.

When an NP is compounding a cream for topical application, the NP is expected to have the manufacturer’s original packaging for the various substances used in the compound. Therefore, when compounding, you must include the manufacturer’s name on the label if the compound is being dispensed to a client.

Is it a conflict of interest for NPs who prescribe a medication to also dispense or sell that medication?

No. The College has developed specific conflict-of-interest provisions to reduce the risk of NPs finding themselves in a position of conflict. For example, NPs cannot charge “dispensing fees” or obtain a profit from the sale of a medication.

NPs cannot obtain any benefit as a result of prescribing, dispensing or selling medication. A “benefit” is defined as any financial or non-financial incentive, whether direct or indirect, that conflicts with an NP’s professional or ethical duty to a client. NPs are expected to base treatment decisions on best available evidence, clinical judgment and client needs. NPs do not prescribe a particular medication because it is available for sale in the practice setting.

The practice expectations for public protection are described in the Nurse Practitioner practice standard.

Can NPs sell medication? Can I ask an administrative assistant to conduct the financial transaction associated with selling medication?

    • the client does not have reasonable access to a pharmacy
    • the client would not otherwise receive the medication
    • the client does not have the financial resources to otherwise obtain the medication, or
    • the medication is sold as part of a health promotion initiative.

Yes, NPs can sell medication. Before you sell a medication, you are accountable for assessing the client to determine that at least one of the following circumstances exists:

NPs cannot charge more than the actual cost of the medication, neither for personal financial gain nor to account for overhead or any other expense incurred.

Although NPs cannot delegate the sale of medication, if the above circumstances are met, an administrative assistant may conduct the financial transaction, which is the only one aspect involved in a sale.

For further information about the practice expectations for public protection when selling medication, see the Nurse Practitioner practice standard.

Performing and ordering procedures

Can I apply defibrillation or electrocoagulation?

No. Until the necessary regulations under the Regulated Health Professions Act, 1991 are put in place by government, you must continue to use delegation for applying forms of energy, such as defibrillation or electrocoagulation. For further information about forms of energy, visit NP Practice Resources

The College will advise members through its website, its Quality Practice newsletter and The Standard when the regulatory amendments are approved and take effect.

Can I perform transvenous cardiac pacing? 

No. Although transvenous cardiac pacing is not explicitly listed as a form of energy under the Regulated Health Professions Act, 1991 (RHPA), the College’s interpretation is that this procedure falls under “cardiac pacemaker therapy,” which is listed. Until the necessary regulations under the RHPA are put in place by government, you must continue to use delegation for applying forms of energy. For further information about forms of energy, visit NP Practice Resources.

The College will advise members through its website, its Quality Practice newsletter and The Standard when the regulatory amendments are approved and take effect.

Can I reduce a pulled elbow?

Yes. While there are restrictions on the performance of the controlled act associated with “setting” a dislocated joint, you can reduce a radial head dislocation. You would assess the client to confirm that the injury is not more severe (such as a complete elbow dislocation, for which the standards would require you to consult a physician). The practice expectations for public protection when setting fractures and dislocated joints are described in the Nurse Practitioner practice standard.

Interprofessional practice

Do I require a ‘consulting’ physician?
There is no longer a legal requirement for NPs to establish and maintain a consultative relationship with a physician; therefore, you do not require a ‘consulting’ physician. However, the consultation standards have not changed, in that you are expected to consult physicians and other health professionals when you encounter client care needs beyond the legal scope of NP practice or your individual competencies. Furthermore, some employers require NPs to have a consulting physician (see question below).

To make consulting possible, you would establish a network of other health professionals, as appropriate, to meet client care needs. If your current consulting arrangements with physicians meet this objective, then you should continue with those arrangements.

The practice expectations for public protection when providing interprofessional care and consultation are described in the Nurse Practitioner practice standard.

I work in a long-term care home. Why is my employer asking for the name of a ‘consulting’ physician with whom I work?
Notwithstanding the information provided in the question above, certain employers may have specific requirements related to NP consultation. For example, regulations of the Long-Term Care Homes Act, 2007 may require an NP to tell the long-term care home the name of the physician with whom the NP has a consultative relationship. NPs should consult their employers to determine whether specific requirements exist.

 

Still have questions? Call our Practice Line at 416 928-0900 ext. 6397 (toll-free Canada-wide 1 800 387-5526). You can also email your question at any time to ppd@cnomail.org.