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Medical Assistance in Dying: New Guidance Document

On, June 17, 2016, Bill C-14 received royal assent, making it possible for eligible people to receive medical assistance in dying in Canada. The law establishes safeguards for clients and offers protection to health professionals who provide medical assistance in dying, along with people who assist in the process in accordance with the law.

To help Ontario nurses understand their accountabilities, the College has released a new Guidance on Nurses’ Roles in Medical Assistance in Dying.

The College also held a teleconference on July 5 to provide more detailed information on nurses’ accountabilities regarding medical assistance. 

As this is an evolving issue, we ask that you visit www.cno.org/maid often for new and updated information on medical assistance in dying. 

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Tougher consequences for snooping health records

A famous person shows up at a hospital. A colleague has a serious accident. A friend of the family attempts suicide.

A nurse working in the care facility where any of these people are being treated may feel concerned, curious or think their case has some educational value. However, unless a nurse is part of the client’s circle of care, it’s illegal to access their records.

On May 6, 2016, two health workers became the first in Ontario to be convicted under the Personal Health Information Protection Act for snooping into former Toronto mayor Rob Ford’s electronic health record. They were each fined $2,505.

Since then, the Act has been amended to include new measures that protect clients' health information and impose tougher penalties for privacy breaches. The amendments, which were passed on May 18, 2016, make it mandatory to report privacy breaches to the privacy commissioner. It also removed a requirement to prosecute within six months and doubled fines imposed for convictions of privacy breaches to a maximum of $100,000 for an individual and $500,000 for organizations.

The College also holds nurses accountable for adhering to its standards of privacy and confidentiality in their practice. While most nurses strictly observe these standards, there has been a worrying increase in the number of privacy breaches brought before the College. The outcomes of these cases show the College takes breaches of confidential health information seriously. Several nurses have been disciplined for accessing the health records of clients not under their care.

“All complaints from the public or reports from employers about this conduct are screened for the level of risk posed to the public,” says Karen McGovern, Director, Professional Conduct. “Most are investigated. A nurse who is found to have committed professional misconduct may have to pay a fine or be publicly reprimanded by the Discipline Committee. They may be monitored while practising or be suspended from practice. In the most serious cases, a panel has the authority to revoke a nurse’s certificate of registration.”

Review College standards

It’s important that all nurses regularly review the Confidentiality and Privacy — Personal Health Information practice standard. This practice standard defines “personal health information” and outlines the situations in which a nurse can access this kind of information. It also reminds nurses that personal health information belongs to clients and is simply housed in health care facilities.
In addition, nurses need to keep up to date with current privacy legislation, policies and best practices. Best practices are outlined in the Ontario Privacy Commissioner's Circle of Care: Sharing Personal Health Information for Health-Care Purposes.



Read the College’s Annual Report

As Ontario’s regulator of the nursing profession, the College’s focus is firmly on the public’s safety. Nurses are committed to providing safe care, and recent surveys show that Ontarians trust them to do so.

Read the College’s 2015 Annual Report to see what we’re doing to ensure Ontarians receive safe nursing care. In it, we share what we did to improve public safety in 2015, including:

  • asking Ontarians what they need to know to make informed decisions about health care providers, which resulted in the College making available to the public more information about nurses
  • being the public’s voice on several issues, such as sharing our expertise with government on what can be done to prevent privacy breaches and the sexual abuse of patients, and holding nurses accountable for maintaining the confidentiality of patient information
  • implementing a new exam for those applying to become Registered Nurses (RNs)
  • helping nurses understand what they need to do to work safely in the ever-changing health care environment
  • working to ensure both new and experienced nurses have the skills, knowledge and judgment to provide safe nursing care
  • improving our processes, including those related to approving nursing education programs and nurses working across borders.

Our decisions and daily activities are guided by our commitment to continue to meet the public’s expectations and maintain their confidence in nurses.

Go to the 2015 Annual Report to read more about how we’re working to fulfil our mandate of protecting the public.



What nurses should know about psychotherapy

A component of psychotherapy will become a controlled act in the future. The following addresses questions nurses have about psychotherapy and how this change will affect their nursing practice:

What is psychotherapy?

Psychotherapy is defined as “an intense client-therapist relationship which often involves the examination of deeply emotional experiences, destructive behaviour patterns and serious mental health issues.” (Health Professions Regulatory Advisory Council, 2006).

It involves a deep examination of life processes that focus on modifications of behaviour, thinking patterns, cognition, emotional response and social functioning. In order to competently practise psychotherapy, nurses need in-depth knowledge, skill and judgment.

What is the component of psychotherapy that will become a controlled act?

The controlled act is the component of psychotherapy considered to be the highest risk to the client. It does not include all psychotherapy practices and is not defined by a technique. The Regulated Health Professions Act, 1991 (RHPA) will restrict the controlled act component of psychotherapy to certain professions, including nursing.

The controlled act is defined in the RHPA as:

Treating, by means of psychotherapy technique, delivered through a therapeutic 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.”

How will I determine if I’m performing the component of psychotherapy that will become a controlled act?

Based on the RHPA definition above, there are five components in the controlled act and all must be met for you to be performing the controlled act:

  1. You are treating a client
  2. You are applying a psychotherapy technique
  3. You have a therapeutic relationship with the client
  4. The client has a serious disorder of thought, cognition, mood, emotional regulation, perception or memory
  5. This disorder may seriously impair the client’s judgment, insight, behaviour, communication or social functioning

It is possible you may be performing psychotherapy but not the controlled act of psychotherapy. For example, if only four of the above components apply, you are not performing the controlled act.

You are in the best position to determine whether or not you are performing the controlled act according to the criteria.

The diagram below highlights that the controlled act is one element in the wide ranging practice of counselling and psychotherapy. Many of the activities that nurses frequently engage in share some common traits with psychotherapy but they are not psychotherapy. For example, activities such as health teaching, providing information, encouragement, support or instruction are not psychotherapy.

 

Will I require an order to perform psychotherapy?

When the controlled act component of psychotherapy becomes law, RNs and RPNs will require an order to perform that component just as they do to perform most other controlled acts they have access to, such as administering a substance by injection.

However, you do not need an order to perform psychotherapy if it does not meet the threshold of the five criteria within the controlled act unless sector-specific legislation (e.g. the Public Hospitals Act) or organizational policy requires it.

Can I use the title “psychotherapist”?

Nurses can no longer use the title “psychotherapist” because it is now a protected title. The Psychotherapy Act, 2007 currently restricts its use to members of the College of Registered Psychotherapists of Ontario.

If you perform psychotherapy, you can describe your role without using the “psychotherapist” title. For example, you could state “I’m an RN and I will be using psychotherapy to treat your disorder.”

I’m a nurse and I perform psychotherapy. Should I also register with the College of Registered Psychotherapists of Ontario?

Ultimately, this decision is up to you. As a nurse, if you have the knowledge, skill and judgment to do so, you may perform psychotherapy. Just note that if you are an RN or RPN, you will need an order to perform the component of psychotherapy that will become a controlled act once it is passed into law.



Q&A: For nurses who work with PAs

The College often gets questions from nurses seeking to understand their accountabilities when working with physician assistants (PAs). The following are answers to the most common questions we get.

Who are PAs?

PAs work in a range of health care settings, under the direction of a physician. The role depends on the PA’s competencies, the supervising physician’s area of practice and the duties the supervising physician assigns. Examples include conducting client interviews and taking medical histories, performing physical exams, performing certain controlled acts as delegated by a physician and providing counselling on preventive health care.

Are PAs regulated?

PAs are unregulated care providers (UCPs) and are not accountable to a regulatory body.

Can nurses accept orders from a PA to perform a controlled act?

No. Under the Nursing Act, 1991 nurses can only accept orders for controlled acts from the following regulated health care professionals: physicians, nurse practitioners, chiropodists, dentists and midwives.

Can nurses accept orders from a PA to perform a procedure that is not a controlled act?

If the procedure is not a controlled act, then whether a nurse accepts the order depends on the legislation that is relevant to their setting and organization’s policies. For instance, under provincial legislation, PAs cannot authorize orders in hospitals or long-term care homes. Nurses should check their organization’s policy about who can order a procedure that is not a controlled act. As always, nurses should use their judgment and ensure their practice is consistent with College standards.

If a PA implements a medical directive involving a nurse, is the nurse accepting an order from a PA?

No. The medical directive is a physician’s order. If a PA initially implements a medical directive that authorizes the PA and a nurse to perform a procedure, the nurse is not viewed as accepting an order from the PA. Nurses who find themselves in such a situation, should follow the same steps they would if the PA were not involved. For example, the nurse should ensure that specific client conditions have been met.

In some circumstances, a PA may transcribe an order in a client’s chart based on a medical directive. If this order includes something a nurse will be doing (for instance, performing venipuncture or administering medication), then the nurse is considered to be “co-implementing” a medical directive with the PA.

What are nurses’ accountabilities when implementing a medical directive with a PA?

Before implementing medical directives, nurses should be involved in the development and approval of the directives — if not directly, then through an appropriate nursing representative. Nurses who implement directives must understand how they will be applied in their practice setting. They should apply their own knowledge, skill and judgment to determine if it is appropriate to implement the directive.

Do nurses require delegation when implementing a medical directive with a PA?

Nurses require delegation when performing a controlled act that is not authorized to nursing under the Nursing Act, 1991. The delegation must come from a regulated health care professional who is authorized by legislation to perform the controlled act (for example, a physician). A physician can delegate a controlled act to a PA, giving them the authority to perform the controlled act. However, the PA cannot then delegate the controlled act to a nurse.

Can nurses accept verbal orders communicated through a PA?

No. The only time nurses can accept verbal orders is when the prescriber (in this case, a physician) is unable to document the order. However, if organizational policy supports it, a PA can transcribe a verbal order from a physician into the client’s chart. If the nurse has questions about the order, then the nurse should verify it with the prescriber.

Where can I learn more?

For specific information on the PA role, visit www.healthforceontario.ca and search for “physician assistant.”

To learn more about nurses’ accountabilities while working with unregulated care providers such as PAs, refer to the following resources: