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Last modified: May 16, 2006

RPNs can now initiate certain controlled act procedures

Recently, the government passed changes to the Nursing Act, 1991, which allow RPNs in Ontario to initiate certain controlled act procedures. Previous to the revision, which is now law, only RNs and RN(EC)s were permitted to initiate a controlled act procedure.

In the legislation, initiation refers to a nurse making an independent decision to perform a controlled act procedure; that is, without a client-specific physician’s order or a medical directive. The nurse is accountable for having the knowledge, skill and judgment to determine that a particular controlled act procedure is indicated for a particular client, and for being competent to perform the procedure safely, effectively and ethically.

While the amended regulation permits RPNs to independently initiate certain controlled acts for their own clients, RPNs are not permitted to order a controlled act procedure for another nurse to perform. RPNs may now initiate the following procedures:

  • cleanse, soak or dress a wound below the dermis or mucous membrane;
  • put an instrument beyond the nasal passages where they normally narrow, beyond the larynx and beyond the opening of the urethra to assist an individual with health management activities;
  • put a hand or finger beyond the individual’s labia majora for the purpose of assisting an individual with health management activities; and
  • put an instrument or finger beyond the client’s anal verge for the purpose of assessing and/or assisting a client with health management activities.

The knowledge, skill and judgment to initiate are greater and different than the competence to perform the activity. An RPN who initiates a procedure is accountable for assessing the client and identifying the problem while considering all of the available options for addressing the problem, weighing the risks and benefits associated with each option, determining the course of action after considering the predictability of the outcomes, and the ability to manage the outcomes of the procedure. The RPN must also document the rationale behind the decision to initiate a procedure.

Before you initiate

It is important to note that while RPNs now have the authority to initiate, in practice the opportunity may be limited by other legislation. For example, regulation 965 of the Public Hospitals Act requires treatment orders for the majority of procedures performed by nurses. As well, employer policies and role descriptions may limit initiation opportunities. RPNs are advised to clarify their role responsibilities with their employers.

In March 2001, College Council approved a motion to revise the initiation regulations in the Nursing Act. The draft regulations were published in the September 2001 issue of Communiqué (now The Standard) and submitted to the Ministry of Health and Long-Term Care for approval.

For more information on initiation, refer to the RHPA: Scope of Practice, Controlled Acts Model reference document.

Scenario: RPN initiation

On Friday afternoon, Lakida, an RPN working in the community, arrives at the home of Mr. Jones, who has a chronic respiratory illness. Mr. Jones tells Lakida that he has a cut on his foot. While examining his foot, Lakida asks Mr. Jones how he cut his foot and when he had his last tetanus immunization. Lakida notes an open wound about three centimetres in diameter on his left foot. His next appointment with the family physician is on Monday morning.

With the legislation revision, Lakida knows that RPNs can now independently decide to perform the controlled act procedure of cleansing, soaking or dressing a wound below the dermis or mucous membrane. She decides to initiate the procedure rather than wait for the family physician to provide orders for wound care during the appointment. Lakida recognizes that over the weekend, the wound could become infected and result in serious complications.

Lakida has taken an advanced wound-care course and knows she has the knowledge, skill and judgment to determine that wound care is necessary and to perform the procedure.

While dressing the wound, Lakida tells Mr. Jones that should anything change with the wound or the dressing over the weekend, he should contact the homecare agency for instructions. After finishing the procedure, Lakida documents her clinical decision-making and the care she has provided in Mr. Jones’ chart.

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