When considering your scope of practice, it is important to understand where a nurse’s authority to perform activities comes from. While the Scope of Practice standard outlines principles and expectations of authority and authorizing mechanisms, additional information may support understanding of how the various authorizing mechanisms apply to different settings and situations. Each authorizing mechanism serves a specific purpose and should not be used interchangeably. Recognizing these differences helps nurses understand their accountabilities and ensure they have the appropriate authority before performing activities or controlled acts.
What is a controlled act?
The Regulated Health Professions Act, 1991 (RHPA), which governs all regulated health professions, sets out what “controlled acts” are. Controlled acts are acts related to health care services that, if performed by an individual without the appropriate qualifications and competence, could harm the public. The health professions regulated under the RHPA are authorized by profession-specific legislation to perform certain controlled acts.
The Nursing Act, 1991, specifies which controlled acts nurses are authorized to perform.
See the Scope of Practice standard for the controlled acts authorized to nurses.
Examples of controlled acts from the RHPA authorized to nurses
Administering an inhalation treatment to a client involves the controlled act of administering a substance by inhalation.
Inserting a peripheral intravenous catheter involves the controlled act of performing a prescribed procedure below the dermis.
What is a direct order?
Direct orders are client-specific orders, including prescriptions and treatment orders, that authorize a procedure, treatment, medication, or other activity for an individual client. Direct orders are based on an appropriate client assessment and the client’s needs, supporting safe care delivery.
- For a medication prescription, a direct order includes the client’s details, medication dose, directions for use, frequency and duration.
- For a procedure, a direct order includes details such as where the procedure will be performed, how often, and for how long.
Note: Pending Council approval, CNO will be replacing the term direct order with client-specific order across its standards, guidelines and supporting resources. In this resource, the term direct order is used to align with current CNO documents.
Examples of direct orders
A Nurse Practitioner (NP) assesses a client with a bacterial infection and orders amoxicillin 500 mg by mouth three times daily for 10 days based on the client's specific condition and treatment needs.
An NP assesses a client with a pressure injury on their coccyx and orders a wound care treatment plan that includes cleansing the wound, applying a dressing every three days, and reassessing the wound weekly. The order is written specifically for that individual client's condition and care needs.
What is a directive?
A directive is an order that authorizes care for a group of clients who meet specific conditions or criteria. Rather than being written for one specific client, a directive allows care to be provided to any client who meets the defined criteria.
Organizational policies and processes support the safe implementation of directives. The authorized provider and those who will be implementing the directive should work together to develop and maintain the directive in accordance with the Directive practice guideline. This helps ensure the directive is clear, appropriate and can be applied consistently. A directive remains an order, and the authorized provider who issues it retains responsibility for the order.
Example of a directive
If a client presents to the emergency department with a suspected heart attack, a directive allows a Registered Nurse (RN) or a Registered Practical Nurse (RPN) to perform a timely electrocardiogram, administer aspirin and/or draw blood based on their assessment, without waiting for a client-specific order.
What is the difference between a direct order and a directive?
The key difference is who the order applies to:
| Direct Order |
Directive |
| Applies to one individual client |
Applies to multiple clients who meet defined criteria |
| Contains instructions based on that client's specific circumstances |
Contains instructions for a group of clients based on pre-defined conditions and eligibility criteria |
| Based on authorized provider’s assessment of the client. |
Based on the nurse’s assessment to ensure the client meets directive criteria |
Regardless of whether a direct order or directive is being used, nurses are accountable for ensuring that it is clear, complete and appropriate. If it is not, nurses must pause and follow up with the authorized provider before proceeding with next steps.
Note: assessments may be informed by information obtained directly from the client, other health care providers and relevant clinical documentation.
What is delegation?
Delegation has a specific meaning in the RHPA that relates to controlled acts. Delegation is the temporary transfer of authority to perform a “controlled act” from a regulated health professional who has the legal authority to perform the controlled act (for example, a nurse) to someone who does not. Delegation is different from an order and is a separate way of authorizing a person to perform a controlled act.
If an individual is not authorized by legislation to perform a controlled act, whether they are regulated or unregulated, they may perform the controlled act by having it “delegated” to them by a regulated care provider who is authorized to perform the controlled act by their health profession’s act.
While delegation transfers authority for the performance of a controlled act, it does not transfer accountability for the overall nursing care of the client. This means, the nurse responsible for the client's care remains accountable for appropriate assessment, care planning, monitoring and follow-up.
Note: Certain regulated health professions have requirements that limit the performance of controlled acts based on legislation and/or their regulatory body. Nurses should encourage the regulated health professional to consult with their regulatory body regarding any profession-specific requirement or limitations in specific areas of practice (for example, in aesthetic services).
Example of delegation
An RN delegates the controlled act of administering a substance by injection to an unregulated care provider (UCP) to give a vitamin B12 injection to a client. The RN ensures that all delegation requirements outlined in the Scope of Practice standard are met and organizational policies permit the delegation. The RN remains accountable for the client's overall nursing care, including assessment, monitoring, and follow-up.
What should a nurse consider before delegating?
The Scope of Practice standard outlines the requirements for delegating controlled acts that must be met.
Before delegating, nurses should consider questions such as:
- Does the nurse have the knowledge, skill and judgment to perform the controlled act themselves?
- Is delegation appropriate in this situation?
- Does the person receiving the delegation have the knowledge, skill and judgment to perform the activity safely?
- Are the client's needs and circumstances appropriate for delegation?
- Can appropriate supervision and support in this specific case be provided?
- Can client safety be maintained throughout all points of care?
Note: While nurses can delegate certain controlled acts, there are restrictions on what they can delegate. Nurses must be familiar with the delegation requirements and limitations outlined in the Scope of Practice standard before delegating a controlled act.
Is delegation the same thing as an order?
No, an order authorizes what care is to be provided to the client.
Delegation allows an individual to perform a controlled act set out in the RHPA when they would not otherwise have authority to do so.
Can an order and delegation both be required?
Yes. Sometimes an activity requires both an order and delegation.
Example
An NP orders an MMR vaccine for a client for a RN to administer. The order authorizes the immunization. However, if a UCP will administer the vaccine, the UCP must first have the controlled act of administering a substance by injection delegated to them by the RN. The order authorizes the treatment, while the delegation authorizes the UCP to perform the controlled act.
Do nurses need delegation to perform controlled acts?
It depends. NPs, RNs and RPNs do not require delegation for the controlled acts they are authorized to perform as set out in the Nursing Act, 1991. However, nurses need delegation to perform a controlled act they are not authorized to perform.
Examples
An RN administering a substance by injection requires an appropriate order, but not delegation, because the nurse already has the authority to perform the controlled act of administering a substance by injection as set out in the Nursing Act, 1991.
An RN would require delegation and an order from an NP or physician to perform the controlled act of communicating a diagnosis to a client.