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This section is intended to support NPs in their understanding and application of the Nurse Practitioner practice standard.
NP practice is conducted within the context of the therapeutic nurse-client relationship. As always, NPs continue to provide health services (e.g., prescribe medication, perform procedures, etc) in accordance with the legal scope of NP practice, College standards and based on the following factors:
For a complete description of the expectations for public protection that apply to NP practice, please see the Nurse Practitioner practice standard.
You must sign as either Nurse Practitioner (NP) or Registered Nurse, Extended Class [RN(EC)]. You may also add your specialty certificate designation:
No other variations of the NP title may be used.
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.
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.
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, or the hospital, should have a system in place for reviewing the tests you have ordered and following up with clients when significant results are received. The nature of the follow-up will vary depending on the situation. For example, clients may be referred to the primary health care (PHC) provider for ongoing care, or a hospital outpatient clinic. You are required to document that you have informed clients of results and the directions for follow-up that you provided.
Safe transfer of accountability is facilitated by a timely discharge summary, including information about tests that have been ordered. To promote continuity of care, you can include a specific request on laboratory and diagnostic requisitions to have test results sent to both the hospital and the PHC provider.
You are accountable for communicating with clients the clinical significance of the tests being ordered, timelines for when they should undergo the test, potential implications of not undergoing the test, what type of follow-up to expect, and the process for communicating results to the client. You may want to provide a copy of the discharge summary to clients, which facilitates safe transfer of accountability. These discussions with clients should be documented.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.