College of Nurses of Ontario, Submission to HPRAC respecting the ...

prescribing the forms of energy that a member may order for the purpose of paragraph 2 6 ofsection 5.1 (1) and prescribing the purpose for which, or the circumstances in which, the form ofenergy may be applied or ordered;(d)designating the drugs that a member may prescribe for the purpose of paragraph 3 of subsection5.1 (1) and prescribing the circumstances in which a member may prescribe the drugs;(e)prescribing standards of practice respecting the circumstances in which registered nurses whohold an extended certificate of registration should consult with members of other healthprofessions. 1991, c. 32, s. 14; 1997, c. 9, s. 3 (1).Incorporation by reference(2)A regulation under clause (e) (b) or (c) may adopt by reference, in whole or in part and with suchchanges as may be necessary, any document or publication and may require compliance with thedocument or publication.Transition before Act in force16. (1)The transitional Council is the Council of the College of Nurses of Ontario as it exists from time totime between the 25th day of November, 1991 and the day this Act comes into force.Powers of transitional Council(2)After the 25th day of November, 1991 but before this Act comes into force, the transitional Counciland its employees and committees may do anything that is necessary or advisable for the cominginto force of this Act and that the Council and its employees and committees could do under thisAct if it were in force.Idem(3)Without limiting the generality of subsection (2), the transitional Council may appoint a Registrarand the Registrar and the Council’s committees may accept and process applications for the issueof certificates of registration, charge application fees and issue certificates of registration.Powers of Minister(4) The Minister may,(a)review the transitional Council’s activities and require the transitional Council to provide reportsand information;(b)require the transitional Council to make, amend or revoke a regulation under this Act;(c)require the transitional Council to do anything that, in the opinion of the Minister, is necessary oradvisable to carry out the intent of this Act and the Regulated Health Professions Act, 1991.Transitional Council to comply with Minister’s request(5)6

If the Minister requires the transitional Council to do anything under subsection (4), the transitionalCouncil shall, within the time and in the manner specified by the Minister, comply with therequirement and submit a report.Regulations(6)If the Minister requires the transitional Council to make, amend or revoke a regulation underclause (4) (b) and the transitional Council does not do so within sixty days, the LieutenantGovernor in Council may make, amend or revoke the regulation.Idem(7)Subsection (6) does not give the Lieutenant Governor in Council authority to do anything that thetransitional Council does not have authority to do.Expenses(8)The Minister may pay the transitional Council for expenses incurred in complying with arequirement under subsection (4). 1991, c. 32, s. 16.Transition after Act in force17. (1)After this Act comes into force, the transitional Council shall be the Council of the College if it isconstituted in accordance with subsection 9 (1) or, if it is not, it shall be deemed to be the Councilof the College until a new Council is constituted in accordance with subsection 9 (1) or until oneyear has elapsed, whichever comes first.Terms of members of transitional Council(2)The term of a member of the transitional Council shall continue for as long as the transitionalCouncil is deemed to be the Council of the College.Vacancies(3)The Lieutenant Governor in Council may appoint persons to fill vacancies on the transitionalCouncil. 1991, c. 32, s. 17.7

Appendix B: Proposed Legislative & Regulatory AmendmentsPROPOSED CHANGES TO REGULATION 275/94 UNDER THE NURSING ACTPART III: CONTROLLED ACTS14. All procedures on tissue below the dermis or below the surface of a mucousmembrane are prescribed for the purpose of paragraph 1 of section 4 of the Act.O. Reg. 115/96, s. 10.15. (1) For the purpose of clause 5 (1) (a) of the Act, a registered nurse in thegeneral class may perform a procedure set out in subsection (4) if he or she meets all ofthe conditions set out in subsection (5). O. Reg. 115/96, s. 10.(2) For the purpose of clause 5 (1) (a) of the Act, any member may perform aprocedure set out in subsection (4) if the procedure is ordered by a registered nurse inthe general class or a registered nurse in the extended class. O. Reg. 39/98, s. 9.(3) No registered nurse in the general class shall order a procedure set out insubsection (4) unless he or she meets all of the conditions set out in subsection (5).O. Reg. 39/98, s. 9.(4) The following are the procedures referred to in subsections (1), (2) and (3):1. With respect to the care of a wound below the dermis or below a mucousmembrane, any of the following procedures:i. cleansing,ii. soaking,iii. irrigating,iv. probing,v. debriding,vi. packing,vii. dressing.2. Venipuncture to establish peripheral intravenous access and maintain patency,using a solution of normal saline (0.9 per cent), in circumstances in which,i. the individual requires medical attention, andii. delaying venipuncture is likely to be harmful to the individual.3. A procedure that, for the purpose of assisting an individual with healthmanagement activities, requires putting an instrument,i. beyond the point in the individual’s nasal passages where they normallynarrow,ii. beyond the individual’s larynx, oriii. beyond the opening of the individual’s urethra.4. A procedure that, for the purpose of assessing an individual or assisting anindividual with health management activities, requires putting an instrument orfinger,i. beyond the individual’s anal verge, orii. into an artificial opening into the individual’s body.5. A procedure that, for the purpose of assessing an individual or assisting anindividual with health management activities, requires putting an instrument, handor finger beyond the individual’s labia majora. O. Reg. 115/96, s. 10.8

(5) The following are the conditions referred to in subsections (1) and (3):1. The registered nurse has the knowledge, skill and judgment to perform theprocedure safely, effectively and ethically.2. The registered nurse has the knowledge, skill and judgment to determine whetherthe individual’s condition warrants performance of the procedure.3. The registered nurse determines that the individual’s condition warrantsperformance of the procedure, having considered,i. the known risks and benefits to the individual of performing the procedure,ii. the predictability of the outcome of performing the procedure,iii. the safeguards and resources available in the circumstances to safely managethe outcome of performing the procedure, andiv. other relevant factors specific to the situation.4. The registered nurse accepts sole accountability for determining that theindividual’s condition warrants performance of the procedure. O. Reg. 115/96,s. 10.16. Sections 14 and 15 shall not be interpreted as authorizing a member to prescribea drug as defined in subsection 117 (1) of the Drug and Pharmacies Regulation Act.O. Reg. 115/96, s. 10.17. To be revoked.18. (1) For the purposes of paragraph 6 of section 5.1 of the Act, a registered nurse inthe extended class may apply the following forms of energy:1. Electricity fori. cardiac pacemaker therapy,ii. cardioversion,iii. defibrillation,iv. electrocoagulation,v. fulguration,orvi. transcutaneous cardiac pacing.2. Soundwaves for diagnostic ultrasound.(2) For the purposes of paragraph 6 of section 5.1 of the Act, a registered nurse inthe extended class may order the application of the following forms of energy:1. Electricity fori. cardiac pacemaker therapy,ii. cardioversion,iii. defibrillation,iv. electrocoagulation,v. electromyography,vi. fulguration,vii. nerve conduction studies, orviii. transcutaneous cardiac pacing.2. Electromagnetism for magnet resonance imaging.3. Soundwaves for diagnostic ultrasound.19. To be revoked.9

20. To be revoked and the following substituted:20. (1) The document entitled "Practice Standard: Performance of Controlled Acts byNurse Practitioners", "Standards of Practice Relating to the Performance of ControlledActs by Nurse Practitioners", as published by the College in [insert month] 200■, isprescribed as a standard of practice for the profession.(2) The College shall ensure that the standards of practice referred to in subsections(1) is circulated among members who hold an extended certificate of registration as aregistered nurse and that it is available to the public upon request.(3) Each member who holds an extended certificate of registration as a registerednurse and who performs any act authorized to the member under section 5.1 of the Actshall ensure that the standards of practice referred to in subsection (1) is complied with.10

Appendix B: Proposed Legislative & Regulatory AmendmentsSummary TableExisting Provision Proposed Change Rationale1 Authorized acts4. In the course of engaging inthe practice of nursing, amember is authorized, subjectto the terms, conditions andlimitations imposed on his orher certificate of registration, toperform the following:Authorized acts4. In the course of engagingin the practice of nursing, amember, other than onewho holds an extendedclass certificate ofregistration as a registerednurse, is authorized, subjectto the terms, conditions andlimitations imposed on his orher certificate of registration,to perform the following:Controlled actsauthorized to the generalclass and the extendedclass have beenseparated to clarifyissues related toauthorization. Seeproposed changes toSection 5.1 for moredetail.2 Authorized acts by certainregistered nurses5.1 (1) In the course ofengaging in the practice ofnursing, a member who is aregistered nurse and who holdsan extended certificate ofregistration in accordance withthe regulations is authorized,subject to the terms, conditionsand limitations imposed on hisor her certificate of registration,to perform the following acts inaddition to those the member isauthorized to perform undersection 4:Authorized acts by certainregistered nurses5.1 In the course ofengaging in the practice ofnursing, a member whoholds an extended classcertificate of registration as aregistered nurse isauthorized, subject to theterms, conditions andlimitations imposed on his orher certificate of registration,to perform the following:All controlled acts thatRN(EC)s have access tohave been moved toSection 5.1. This isintended to clarifyRN(EC) authorityrespecting theperformance of and theauthority to order othersto perform controlledacts. Further, thecontrolled acts forRN(EC)s have beenbroadened to includeadditional controlledacts;• setting or casting afracture of a bone ora dislocation of ajoint; and• compounding,dispensing, andselling drugs.These changes asdiscussed below areintended to reflectcurrent practice ofRN(EC)s and to increaseclient access to healthcare services. Finally,the controlled acts havebeen reordered to be11

Existing Provision Proposed Change Rationaleconsistent with the orderthey appear in Section27 (2) of the RegulatedHealth Professions Act3 1. Communicating to a patientor to his or her representative adiagnosis made by the memberidentifying, as the cause of thepatient’s symptoms, a diseaseor disorder that can beidentified from,i. the patient’s health history,ii. the findings of acomprehensive healthexamination, oriii. the results of any laboratorytests or other tests andinvestigations that the memberis authorized to order orperform.1. Communicating adiagnosis identifying adisease or disorder as thecause of a person’ssymptoms.(1991) or RHPA.Conditions respectingthe communication of adiagnosis have beenremoved from the Act.These conditions forcommunicating adiagnosis moreappropriately reflect astandard of practice. Bymoving these conditionsto a standard, a membernot practising inaccordance with thestandard would moreappropriately faceprofessional conductreview rather thanpotentially be subject tocriminal charges.4 2. Ordering the application of aform of energy prescribed bythe regulations under this Act.Re-numbered andbroadened – See #6 belowin this columnTo help ensureenforceability, conditionsrespecting theperformance of allcontrolled acts byRN(EC)s will be placedin the Practice Standard.3. Prescribing a drugdesignated in the regulations.5 Performing a procedure ontissue below the dermis orbelow the surface of a mucousmembrane.Re-numbered andbroadened – See #7 belowin this column.2. No change in content.Re-numbered, i.e., movedfrom Section 4.0 to 5.1 forRN(EC)s only.6 New 3. Setting or casting afracture of a bone or aMoved to enhance clarityrespecting RN(EC)authority to perform thecontrolled act andauthority to order othersto perform it.New controlled act –common procedures12

Existing Provision Proposed Change Rationale7 4. Administering, by injection orinhalation, a drug that themember may prescribe underparagraph 3.8 5. Putting an instrument, handor finger,i. beyond the external earcanal,ii. beyond the point in the nasalpassages where they normallynarrow,iii. beyond the larynx,iv. beyond the opening of theurethra,v. beyond the labia majora,vi. beyond the anal verge, orvii. into an artificial opening intothe body.dislocation of a joint4. Administering asubstance by injection orinhalation.Moved from Section 4.0 to5.1, and combined withexisting provision under5.15. No change in content.Re-numbered, i.e., movedfrom Section 4.0 to 5.1 forRN(EC)s only.performed by RN(EC)(e.g. radial headsubluxation and shoulderdislocation).Performance of thesecontrolled acts may besubject to conditions instandards as discussedabove.This change removesconditions respectingwhich drugs RN(EC)shave the authority toorder and administer andenhances clarityrespecting RN(EC)authority to order othersto perform the controlledact.Moved to enhance clarityrespecting RN(EC)authority to perform thecontrolled act andauthority to order othersto perform it.9 2. Ordering the application of aform of energy prescribed bythe regulations under this Act.6. Applying or ordering theapplication of a form ofenergy prescribed by theregulations under this Act.With the varied contextsof practice of RN(EC)s(e.g. acute care adult,paediatrics, PHC, etc.),NPs will require accessto a broader list ofprescribed forms ofenergy. To provideRN(EC)s with additionalauthorities the controlledact has been expandedto include both applyingand ordering certainforms of energy asdefined in the13

Existing Provision Proposed Change Rationaleregulations. (SeeSection 18 of theproposed changes to thecontrolled actsregulation). Thecontrolled act has alsobeen re-numbered forconsistency with the10 3. Prescribing a drugdesignated in the regulations.7. Prescribing, dispensing,selling or compounding adrug.RHPA.Broadened by removingreference to drugschedules or lists inregulations. This willallow open prescribingwhich will enableRN(EC)s to meet theneeds of their clients,keeps pace with currentpractices, and isresponsive to thepractice needs of threenew proposedspecialties of RN (EC) s.11 (2) A member is not authorizedto communicate a diagnosisunder paragraph 1 ofsubsection (1) unless themember has complied with theprescribed standards ofpractice respecting consultationwith members of other healthprofessions. 1997, c. 9, s. 2.Deleted.Three new componentsto this controlled act –dispensing, selling andcompounding areproposed in order tokeep pace with currentpractice. The controlledact has also been renumberedforconsistency with theRHPA.Conditions respectingthe communication of adiagnosis have beenremoved from the Act.These conditions forcommunicating adiagnosis moreappropriately reflect astandard of practice. Bymoving these conditionsto a standard, a membernot practising inaccordance with the14

Existing Provision Proposed Change Rationalestandard would moreappropriately faceprofessional conductreview rather thanpotentially be subject tocriminal charges.16 Regulations14. (1) Subject to theapproval of the LieutenantGovernor in Council and withprior review by the Minister, theCouncil may make regulations,(c) prescribing the forms ofenergy that a member mayorder for the purpose ofparagraph 2 of subsection5.1 (1) and prescribing thepurpose for which, or thecircumstances in which, theform of energy may beapplied;17 (d) designating the drugs that amember may prescribe forthe purpose of paragraph 3of subsection 5.1 (1) andprescribingthecircumstances in which amember may prescribe thedrugs;Regulations14. (1) Subject to theapproval of the LieutenantGovernor in Council and withprior review by the Minister,the Council may makeregulations,(b) permitting a member toperform a (a) andgoverning theperformance of theprocedure (1)procedure under clause5 including, withoutlimiting the foregoing,prescribing the class ofmembers that canperform the procedureand providing that theprocedure may only beperformed under theauthority of aprescribed member or amember of a prescribedclass;(c) prescribing the forms ofenergy that a membermay apply or order forthe purpose ofparagraph 6 ofsection 5.1 andprescribing the purposefor which, or thecircumstances in which,the form of energy maybe applied or ordered;Subparagraph d of Section14 (1) is deletedThe change reflects theproposed revisions toSection 5.1 includingthe re-numbering of thelist of controlled acts,i.e., forms of energy arereferenced in paragraph6 instead of paragraph2, and the additionalauthority to both applyand order the applicationof forms of energy isincluded.The authority to makeregulations for drugs isnot required as the list ofdrugs has been deletedin order to be responsiveto the varied contexts ofpractice in which the fourproposed RN(EC)specialties will practice.Conditions, if any, for15

Existing Provision Proposed Change RationaleRN(EC) prescriptiveauthority will be listed inthe Standards ofPractice Relating to theAuthorizing of Others toPerform Acts Authorizedto Nurse Practitioners[See proposed changesto Controlled Actsregulation Part III,Section 20 (2)].18 (e) prescribing standards ofpractice respecting thecircumstances in whichregistered nurses whohold an extendedcertificate of registrationshould consult withmembers of other healthprofessions. 1991, c. 32,s. 14; 1997, c. 9, s. 3 (1).Subparagraph e of Section14 (1) is deleted.As noted in Section 5.1,to ensure the standardsassociated with theperformance of allcontrolled actsauthorized to RN(EC)sare legally enforceable,rather than only oneaspect of a controlled actauthorized to RN(EC) asreferenced in this clause,a static incorporation byreference provision isincluded in the draftNursing Regulations.This provision enabledunder the RHPA and theNursing Act allow theCollege to developstandards respectingcontrolled acts (SeeSection 20 of theproposed changes to theControlled ActsRegulation).16

Appendix B: Proposed Legislative & Regulatory AmendmentsStakeholder Consultation SummarySUMMARY OF RESPONSESTO THEPROPOSED CHANGES TO THE REGULATIONS RELATED TO THE EXTENDED CLASSTOTAL RESPONSES:17 ORGANIZATIONS AND196 INDIVIDUALSINDIVIDUAL RESPONSESA total of 196 responses were received from individuals.• 166 of the individual responses, or 85%, expressed strong support for the proposals.63 were individually written letters, 103 were form letters arising from a call for actionby the Registered Nurses’ Association of Ontario.• 27 responses were received from Neonatal Nurse Practitioners addressing issues ofparticular concern to those practitioners (see page 2).• 2 respondents did not support the proposals because of the impact on their personalsituations (see page 4).A breakdown of the individual letters and the call for action form letters appear below.Practice examples provided by respondents can be found starting on page 10.Strong and unqualified support for the proposals:• 29 RN(EC)s• 27 ACNPs• 2 students [one RN(EC)]• 5 RNs• 1 unidentifiedThe following comments/themes appeared in the individual letters, with the numbersrepresenting the number of times the comment/theme was included:• proposal will increase access, quality and continuity of care – 33,• proposal will result in increased system capacity – 31,• title protection will increase public safety – 29,• removal of list-based prescribing will allow up-to-date treatment – 19,• recognition of skills and expanded scope will result in increased recruitment andretention – 18,17

• proposal will allow nurse practitioners to serve the public to their full scope – 14, and• removal of requirement to perform under delegation/medical directive will clarifyaccountability – 9.Suggestions for the future:Three correspondents suggested future expansion of the specialties.Recommendations were:• Geriatric – also recommended by Ontario Long-Term Care Association;• Perinatal – since Perinatal ACNPs care for the mother through pregnancy and thewell baby, thus spanning both adult and child; and• One individual did not specify particulars but identified that the “Adult” specialtycovered too large an age range (18 to 100) and needs to be further broken down.RNAO “Call For Action” – Form Letter:103 signatories• 77 unknown/unsigned• 9 Acute Care Nurse Practitioners• 9 Nursing Leaders(Professional Practice Leaders (3), Clinical Team Leader, Manager of PatientSupport, Branch Manager – VON, Director of Clinical Oncology Services,Manager of Clinical and Regulatory Affairs – Addictions, Coordinator of NursePractitioner Program)• 5 Primary Health Care Nurse Practitioners• 3 studentsContents summary:• Strongly support proposed changes.• Changes will serve the public by strengthening the safety and capacity of Ontario’shealth care system.• Enabling all NPs to function autonomously without medical directives or delegationwill clarify lines of accountability.• Title protection will enhance public protection.• The proposed changes will allow RN(EC)s to better serve the needs of Ontarians byenabling them to use their knowledge, skills, and experience, and practice to theirfull scope.NEONATAL NURSE PRACTITIONERS (NNPS):27 Neonatal nurse practitioners (NNPs) and colleagues wrote to the College regardingthe proposals. All were supportive of the move towards the regulation of ACNPs in theextended class. Concerns were expressed, however; about how the neonatal clinicalspecialty would fit within the four regulatory specialties proposed by the College.18

11 NNPs wrote letters concerned about the lack of a separate regulatory specialty forNNPs. A letter was also received from the Coordinator of the Advanced NeonatalNursing Graduate Diploma Program at McMaster University and the Medical Director ofthe Master’s prepared Neonatal Nurse Practitioner Program. The letters (13 in total)were similar in content and the key issues identified were:NNPs provide care to a unique patient base – the neonatal intensive care patients areneonates born prior to term gestation – NNPs identified their perspective that theseclients do not fit with paediatrics (children from 0 to 18) and note that they have verydifferent care needs from the general paediatric stream;• support the need for a uniform educational program for NNPs – to ensureconsistency of high-quality practice;• all identified that the NNPs were implemented to fill a gap in the system and that theNNP role in Canada is at the leading edge for the professional standard of neonatalcare;• noted that the NNP program was the first ACNP education program in Canada andis the only ACNP program that is specialty specific. There is limited generalpaediatric content in the NNP program;.• concern was expressed that the term “paediatrics” was a misnomer for NNPs; and• several queried why the College would propose a specialty for Anesthesia whenthere are no Ontario Nurse Anaesthetists and no Ontario program and not propose aspecialty for NNPs.Two areas of considerable concern that have been identified have subsequently beenaddressed:• Considerable concern was expressed that NNPs would not be able to pass apaediatric examination; members suggested alternatives with the NationalCertification Corporation (US) NP examination most often suggested. In respondingto the letters, and on Q&As on the web site, CNO explained that the proposedregulations provide Council with the authority to recognize more than one exam foreach specialty certificate, and that Council will review options for an examination thatis appropriate to NNP practice.• NNPs do not want to use the title NP – Paediatrics. They feel it does not reflect theirrole and is confusing. It has been clarified that they must use the title NP orRN(EC). They may use their regulatory specialty title (e.g. NP-Paediatric), if theywish, but they may also use their clinical specialty when making reference to title[e.g. NP (neonatal)].1 letter was received from a Regional Coordinator of the Primary Health Care NursePractitioner Program, again supporting the regulatory amendments but suggesting thatCNO further examine the inclusion of NNPs as a regulatory specialty.4 NNPs wrote supporting the proposed changes but also raising concern about theneed for an appropriate examination for NNPs, again recommending the NationalCertification Corporation examination19

9 NNPs from the Neonatal Intensive Care Unit and the Neonatal Developmental FollowupUnit at the Hospital for Sick Children signed a letter supporting the amendments asput forward.• They stated: “We welcome the opportunity to be regulated in the proposed NP –Paediatric specialty certificate of the extended class.”• They also suggest the National Certification Corporation examination as anappropriate examination and the use of a neonatal OSCE to allow candidates todemonstrate their knowledge, skill and judgment in clinical practice.• They state: “It is clear that the proposed amendments will allow infants born withhealth problems in Ontario access to neonatal nurse practitioners as qualified andrecognized members of the interdisciplinary health care team. Regulation within theExtended Class will allow efficient and timely access to care for high-risk infants andfamilies requiring neonatal intensive care, transition to community care and neonataldevelopmental follow-up programs.”NOT SUPPORT PROPOSALS2 RNs• One practicing as an NP through experience and concerned that she will not be ableto continue to use the title; and• One concerned that she cannot translate advanced credentials from another countryto the Ontario NP role, while there is MRA for NPs from other Canadian jurisdictions.ORGANIZATIONAL RESPONSESSeventeen organizations responded to the consultation.Five nursing organizations and five employers or associations representing employersstrongly supported the proposals. Two employers supported the proposal but askedthat Council clarify the examination options for neonatal nurse practitioners and that, inthe future, Council consider expanding the specialties to include NNPs.A response was received from one nursing regulator from another Canadian jurisdictionidentifying no concerns with the proposal.Four Ontario health regulatory bodies responded. Two were supportive of theproposals, one citing the need for regulatory rigor in the standards and for collaborativepractice. Two had concerns about particular aspects of the proposals.The Ontario Medical Association was the only other professional association/union torespond and, with the exception of title protection, it strongly opposes the proposal.The following summarize the key points in the organizational submissions.20

ONTARIO NURSING ORGANIZATIONS5 provincial nursing organizations all strongly supported the changes:• Council of Ontario University Programs in Nursing (COUPN),• Nurse Practitioners’ Association of Ontario (NPAO),• Ontario Nurses’ Association (ONA),• Registered Nurses’ Association of Ontario (RNAO) and• Registered Practical Nurses Association of Ontario (RPNAO).Main themes include:• enhancing access to, and continuity of care, reducing wait-times,• clarifying accountability,• enhancing the safety of the health care system, and• title protection important to public safety – provide clarity for public and otherproviders; ensure those who use title have demonstrated competence.Selected quotes from submissions can be found on page 9.OTHER CANADIAN NURSING JURISDICTIONSL'Ordre des infirmières et infirmiers du Québec• No potential impact of the changes on practice and on the delivery of patient carefor Quebec.OTHER ONTARIO HEALTH REGULATORY BODIESResponses received from four regulatory colleges. All supported aspects of theproposals; specific concerns or caveats identified by Colleges are articulated below:College of Medical Radiation Technologists• Supports the initiative, no objections.College of Physicians and Surgeons of Ontario• Support intention to facilitate access to care .• Expansion of scope is consistent with CPSO’s commitment to fostering collaborativehealth care models if undertaken with the appropriate concern for ensuring theadequate knowledge, skill and judgment of the professionals involved.• No objection to changes in principle – emphasize the need for the utmost regulatoryrigor as the legislative restrictions on scope are reduced.• Support for proposals is based on the intention for the changes to be implementedwithin a collaborative care model, hope that two colleges will continue to worktogether to promote collaborative care by physicians and nurses.21

College of Respiratory Therapists of Ontario• Support the proposed amendments to the Nursing Act.• Called attention to the restrictions posed by Regulation 965 as amended toRegulation 204/06 of the Public Hospitals Act 1 .• Expressed concerns regarding the Specialty – Anesthesia:o Questioned impact on existing roles and programs – e.g. AnesthesiaAssistant;o Perceive the role of NP-Anesthesia as “exclusionary” – will not be open toother disciplines 2 ;o Suggest that not focus on one health care discipline to solve current andfuture shortages, rather encourages CNO and Ministry to explore multidisciplinarymodel of care; ando Recommended further dialogue and continued collaboration with groupssuch as anaesthesiologists, nurses, respiratory therapists and other healthcare providers.Ontario College of Pharmacists• Support for removal of drug and test lists from legislation• Do not support RNs in the extended class performing controlled acts ofdispensing, selling and compounding of drugso Drug and Pharmacies Regulation Act sets out detailed requirements forthese activities, including procedural standards, record keeping andlabelling, etc; CNO’s proposal does not address these requirements 3o An inherent conflict exists where professionals prescribe and dispense;also removes an important check and balance in the system 4• Support enhancement of a profession’s role through collaborative practice andbelieve that identified needs can be, and already are in many instances,accomplished through the delegation/medial directives schemes currentlypermitted under the RHPA.OTHER PROFESSIONS PROFESSIONAL ASSOCIATIONS/UNIONS:Ontario Medical Association• Serious concerns about both the content of the proposed amendments and theconsultation process• OMA identified that the proposed amendments are a significant change to theregulatory framework – recommended referral to HPRAC and impose amoratorium on any changes1 CNO has already communicated to government as per Councils’ approval in June that amendments are required tothis Regulation along with other legislative and regulatory changes to support the Nursing Act and proposedregulation changes.2 CNO has responded to the College to clarify our understanding that the NP – Anesthesia would be part of a multidisciplinarycare team and is in no way exclusionary of other roles, including the Anesthesia Assistant and RT-Anesthetist3 CNO recognizes the changes that are required to the Drug and Pharmacies Regulation Act.4 Physicians have the authority to see, compound and dispense as well as prescribe.22

• Liability issues need to be addressed – concerned that there will be gaps in careif legal accountabilities are not addressed• Concern re. the removal of the prescribing lists – see the current lists as publicprotection with existence of external review to ensure appropriate decisions aremade• Does not support RN(EC)s setting or casting a fracture• Does not support the changes regarding applying and ordering forms of energy –will result in a significant and inappropriate expansion of scope of practice• Does not support changes to controlled act re. drugs, identified that physiciansare more limited in ability to dispense, sell or compound drugs than in proposal –can only do when pharmacist’s services are not reasonably readily available(regulation under Medicine Act)• Supports protection of the title Nurse PractitionerEMPLOYERS AND ASSOCIATIONS REPRESENTING EMPLOYERS:Cancer Care Ontario:• Strong support – identified proposals as crucial to planned initiatives to meetgrowing needs.• Majority of advanced practice nurses working in cancer care are ACNPs workingunder medical directives.• Ontario Cancer plan (2005-2008) recognized that the delivery of cancer servicesneeds to be transformed to meet current and future demand; called for innovationin health human resources.• Incidence of cancer expected to increase 38.5% in next decade.• Cancer Care Ontario has made the commitment to oncology NPs and committedresources to support oncology courses within ACNP program at the University ofToronto.“In light of the increasing demand for cancer services; the need for innovation tomeet the challenges; increasing initiatives in prevention and screening, andaccess issues across the province, it is critical that the proposed changes beeffected to support patient needs in Ontario. The proposed amendments areessential to support and advance the role of Nurse Practitioners in the cancersystem.”Hamilton Health Sciences• Support the four specialties in the extended class as well as the mutualrecognition agreement.• Support current direction of CNO regarding moving forward with regulatorychanges with the four specialties.• Request clarification of examination process for Neonatal Nurse Practitioners.• Request that Council consider inclusion of Neonatal Nurse Practitioners as aspecialty in the future.Hospital for Sick Children• Support – employ over 60 ACNPs.23

• Support four streams and title protection to enhance public safely and facilitateaccess to care.• Proposed changes are congruent with current approaches to health humanresource planning and will greatly enhance the capacity of nurses to better servethe public in the delivery of specialized health services.Ontario Association of Non-Profit Homes and Services for Seniors• Support proposals.• Will remove barriers to nurse practitioner practice and support more fully the roleand scope of the nurse practitioner across the continuum of care.• Support inclusion of ACNP and four specialties.• Broadening of NP prescribing rights to include ordering of alternate forms ofenergy and diagnostic testing will enhance access to NPs by Ontarians.Ontario Long Term Care Association• Represent 428 private, not-for profit long term care homes which provide careand services to almost 50,000 residents and employ approximately 10,000registered nursing staff.• Support proposals – “amendments support the underlying principles of both selfregulationand protection of the public, while responding to the demands ofcurrent and future practice of Nurse Practitioners. We also see theseamendments as important steps in supporting provincial health human resourcestrategies required to make full use of the skills of health professionals inproviding efficient and effective health care.”o Support changes to Controlled Acts.o See Mutual Recognition provisions as “another effective policy buildingblock in addressing health human resources in Ontario”.o Support the proposed regulatory framework of four specialties at this time.o Recommends strengthening geriatric component in NP education and thedevelopment of competencies for NP in geriatric specialty.St. Elizabeth Health Care• Support the proposals – will remove many of the barriers to appropriate utilizationof NPs• We praise the CNO for recognizing the growing needs of our health care systemby proposing that Acute Care Nurse Practitioners be included in the ExtendedClass. This will resolve many of the barriers associated with ACNPs practicingwith medical directives by granting authority to independently perform a numberof controlled acts. In addition, this will have the added benefit of regulatingACNPs through the RN(EC) registration process which will protect the public byensuring that ACNPs meet Extended Class standards.• Noted that at this time, most ACNPs work in large urban centres, the ability topractice independently may facilitate a shift for the ACNP from hospital to rural,under-serviced regions, thereby enhancing and expanding access to care.• There is widespread confusion about the NP role among health careprofessionals. Title protection is an effective solution and would facilitate24

communication with the public and other stakeholders as to the NursePractitioner role and the qualifications of those practicing in the role.• An understanding of the NP role is vital and would improve community basedcare.1. Community nurses are frequently unsure of what can and what cannot beordered by the NP. Order and authority clarification take time in thecommunity. The visiting nurse is limited in her “at-hand” resources.Comprehension of the NP role will eliminate this need for confirmation.2. The Nurse Practitioner Workforce Survey and NPAO Electronic RegistryProject Report (2006) reported that ACNPs cited, “nurses did not work withthem” and “nurses refuse to accept a verbal or telephone order from them.”Accurate perception of the NPs scope of practice may encourage acollaborative, mutual relationship between nurses and NPs.3. Title protection would facilitate trust in the NPs knowledge and education.SPECIFIC COMMENTSNurse Practitioners’ Association of Ontario• …the proposed changes are an important step forward in strengthening the safety ofOntario’s health care system. These proposals also provide an opportunity toexpand the capacity of the health care system to meet the current and future needsof people of this province.• Enabling nurses in the Extended Class to function autonomously without medicaldirectives or delegation strengthens professional accountability and ensures thatpatients have access to comprehensive, safe, quality care.• These changes will provide more timely access to care for patients, facilitate earlierdischarge for patients and reduce waiting times, improve continuity of care, supportbest evidence in prescribing and remove unnecessary burdens and promote moreeffective utilization of physician resources.Ontario Nurses’ Association• Supports title protection and changes to Controlled Acts.• ONA also supports the removal of most of the conditions for the performance ofControlled Acts, authorizing an RN(EC) to write orders for Controlled Acts to becarried out by other nurses. We believe this will improve wait/service times inclinics/emergency departments.Registered Nurses’ Association of Ontario• The proposed regulations protection of the public’s safety by ensuring stringentcompetency requirements is consistent with the responsibilities of a self-regulatingprofession. …enabling all RN(EC)s to function autonomously without medicaldirectives or delegation sharpens lines of accountability.• RNAO endorses regulatory and legislative changes that will facilitate implementationof the recommendations in numerous reports which urge maximizing thecontributions of all health professionals to increase access to health services.25

• By enabling NPs – Anesthesia to provide anaesthesia care autonomously withintheir scope of practice – preoperatively, intraoperatively, and postoperatively –access to anaesthesia services will be improved and surgical wait times will bedecreased.Registered Practical Nurses Association of Ontario• The changes will allow for greater flexibility and access to quality care within thecomplex changing health care system. …these changes will support the public tobetter understand who is the nurse practitioner and what their role may include intheir specific area of practice. Which will further support the public in their ownpersonal decision in accessing care.SELECTED EXAMPLES FROM THE FEEDBACKREMOVAL OF THE DRUG AND TEST LIST• I support the proposal to eliminate the drug, laboratory and diagnostics list. I haveworked autonomously within my scope of practice however have, on manyoccasions, needed to consult with physicians when I could have practicedcompetently without consultation had I not been limited by the inadequate andoutdated drug, laboratory and diagnostic list. The arbitrary limits caused by the listhas caused delays in obtaining the most appropriate care for the patient as well asunnecessary burdens on both my time and the collaborative physician’s time. Whenmy collaborative physician has been unavailable, I have needed to send the patientto a walk-in clinic or the emergency department or have been pressed to prescribe aless appropriate drug or limit testing in order to comply with the limitations of the list.• The drug list causes problems in my practice on a daily bases. Here are a fewexamples. Several patients have asked me for the Evra patch as a method of birthcontrol but this drug is not currently on the NPs list of medication. This summerwhen the physician I partner with was on holidays, some patient’s drugs came up forrenewal. I was unable to renew them and had to send the patient’s to the hospitalemergency to get a prescription for drugs they have been on for extended periods oftime. This is a waste of everyone’s time and resources.• Having prescriptive authority in the in-patient setting will facilitate timely discharge ofpatients from the hospital. This would improve efficiency of patient transfer, as bedsbecome available sooner for patients waiting in the recovery room, the intensivecare unit and in the emergency department.• A specific example of improved RN(EC) scope of practice in my role as aCardiologist is with a Heart Function Clinic (Heart Failure). The NP assists in thefollow up care, monitoring and education of patients with Congestive Heart Failure.The NP sees patients every Tuesday, she assists in monitoring signs and symptomsof heart failure and blood work results, ordering outing blood work and educatingpatients and detecting early signs and symptoms of their condition. If a patientbecomes short of breath, it is the NP who assesses and suspects early congestive26

heart failure but is limited in her ability as she is not able to titrate or initiate diuretic(water pills) and she is also not able to order a BUN which is basic (evidence based)blood work to monitor a patient with congestive heart failure. The NP also cannotorder an echocardiogram as full up care for a patient with CHF or blood work (a CK)required to monitor a patient on cholesterol medications.REMOVAL OF NEED FOR DELEGATION/MEDICAL DIRECTIVES• I am one of three ACNPs in the Division of General Surgery at the Hospital for SickChildren. As a key member of the multidisciplinary team, having extended classregistration and being an independent practitioner would enhance my ability tocontribute to the best care for General Surgery patients. With an expanded scopeand an evidence base, I would be able to openly prescribe and order tests within mycompetencies, as opposed to relying solely on medical directives. This would helpme to provide timely care to patients I am involved with. This in turn wouldcontribute to earlier discharge, more support within and outside the hospital forpatients and ensure follow up with less readmission.• In my practice as a member of a pain management team, we assess and evaluatepatients in intractable pain. Our evaluation will improve timely access toanaesthesiologists and specialized pain management procedures. Havingprescriptive authority in an inpatient setting will facilitate continuity of care resultingin earlier discharge of patients in the hospital setting.• I am an acute care nurse manager …In my current role I support the NursePractitioners with the Seniors’ Health Program to collaborate with theinterdisciplinary team members to identify the best plan of care for the patients in ourprogram. With an expanded scope of practice for NPs, they will be able to openlyprescribe within their competencies. Older persons within our program will benefitfrom enhanced continuity of care because NPs will follow them as they move frominpatient to ambulatory clinics to home. Having prescriptive authority in an inpatientsetting will facilitate timely discharge of patients and support our enabling patientaccess initiative.• I negotiated Medical Directives in order to be able to provide patients with servicesto the full scope of NP practice. Although negotiating Medical Directives did enableme to order lab tests, diagnostic tests and medications, the process was arduous.The Medical Advisory Committee (MAC) approval of the second set of directives forthe Internal Medicine role was delayed by almost 1 year. This delay occurredbecause a new member of MAC, who was a board member of OMA, did not like theidea of nurse practitioners. This MAC member was a pathologist (a role with littlecontact with patients and even less understanding of the knowledge, skills andabilities of NPs). This politically motivated delay increased the wait time for patientsneeding Internal Medicine consults in one of the most under serviced areas in theprovince.27

• In my present role (nurse practitioner for Palliative Care/ Pain & SymptomManagement), I do not have directives because I cannot find a physician who willagree to commit to work with palliative care patients in our hospital. My present roleis unique because I am not “attached” to a specific physician group. I act as aconsultant. Requests for consults are made, not only by nurses, but also byphysicians. I write recommendations for treatment in a similar fashion to myphysician specialist colleagues.Unfortunately, unlike my physician colleagues, I do not have the option of writingtreatment orders that can be carried out prior to attending physician approval. Thismeans that patients must wait, sometimes in excruciating pain, until the surgeon isfinished operating or the attending physician calls back. Yesterday, a woman in thelast days of her struggle with lung cancer had to suffer in severe dyspnea and waituntil her doctor called back to approve my suggestions for bronchodilators andopioids.• In my practice, I assess, suggest interventions, evaluate and provide timely accessto diabetes related diagnostics and treatments while working with my endocrinologistpartners. This may include surveillance and prevention of potential microvascularand macrovascular complications, titrating of medications and immediate care topersons after a coronary event or women in labour with diabetes. As an ACNP, I amable to see the patients sooner while my physician colleagues are in their offices.This contributes to higher patient and nurse satisfaction, and potentially moreefficient and effective discharge thereby reducing the high cost of health care.CHANGES TO CONTROLLED ACTS• In the Urgent Care Centre, these changes will allow me to order venipuncture byRegistered Nurses as well as set and cast non-displaced fractures. These changeswill reduce wait times and address issues in a more timely manner subsequentlyimproving patient outcome and efficiency of the health care system. These changeswill also improve efficiency of health care systems by facilitating timely access tophysicians and specialists.• Being able to dispense birth control pills and samples of drugs in my prescribingscope will better serve my patients and improve overall access to quality health care.• I work in an interdisciplinary team with other RNs and RPNs who provideimmunizations, do venipuncture, dressing changes and call in medication renewals.Being able to have them support my practice like they support my physician partnerswill also improve the efficiency of my practice and allow us to practice truly as ateam.• The health care resources are limited in this community and yet I am unable toaccess the services of the community health nurse who assists the physicians. Asan example, she would be happy to draw blood from patients for the tests I order butthe current legislation prevents this.28

• Many people in this community do not have access to a vehicle to get to the closesttown where the pharmacy is. It would be very helpful to have a supply of criticalmedication on hand but I am not allowed to dispense medication, so none is kept atour clinic.• After Mrs. B’s second heart valve replacement, she developed a clot on her heartvalve after an inability to access a family doctor. Upon discharge after her secondheart valve operation, the nurse practitioner arranged for the patient to have a familydoctor. Unfortunately, the family physician was on vacation the week of the patient’sreadiness for hospital discharge and the team decided to keep the patient in hospitalfor an extra four days to prevent risk of another blood clot which could occur withoutaccess to the necessary blood test and medication adjustment. If the nursepractitioner had regulatory authority to order the blood tests and make medicationadjustments, the team would have had the confidence to safely discharge Mrs. Bhome with follow-up by the nurse practitioner until the family physician returned fromvacation.• The removal of conditions for controlled acts and the authority to write orders forthese is important. For example, within a cardiac surgery intensive care unit theapplication of energy is paramount. Part of my role, as ACNP in the cardiac surgeryintensive care unit, is to accept fresh post operative patients who are very unstablein the first few hours. These patients have rapidly changing conditions that requirerapid assessment and response. A major condition change includes a large varietyof cardiac dysrhythmias. The response to these dysrhythmias may be emergencycardiac pacing or even defibrillation or cardioversion. The proposed changes thatsupport me to apply and to order the application of cardiac pacemaker therapy,cardioversion and transcutaneous cardiac pacing will allow me to improve patientoutcomes because it allows me to rapidly respond to patient changes. The ability toorder ultrasound and MRI are also important in my role. Ultrasound is frequentlyused to examine heart function in the critically ill. MRI is often used to establishneurological complications of the cardiac surgery patient. The information from thesetests guides appropriate treatment. Those patients who are diagnosed quickly havetheir issues managed sooner and subsequently can have a shorter length of ICUstay.COLLABORATIVE PRACTICE• I (PHCNP) also consult with an ACNP at the Hotel Dieu Hospital, Kingston,regarding Congestive Heart Failure clients. The Prince Edward Family Health Teamis now planning a rural CHF clinic and the ACNP has been mentoring us by sharingtheir program model and research and is ensuring that we have the latest evidence–based guidelines to ensure safe and effective patient care. This NP and herphysician collaborator lead a very successful CHF program that has proven to behighly effective in managing this chronic disease and has clearly improved healthstatus and decreased the need for hospital admissions.29

• I (PHCNP) consulted the ACNP …. whose area of expertise is in Respirology(paediatric and adult clients). On many occasions, I benefited from her expertnursing opinion regarding asthma or COPD clients. Eventually we planned andimplemented an asthma clinic on a monthly basis, which required her to do outreachtravel to our rural clinic. This was very well received by both the patients and thefamily physicians in our clinic. This clearly improved patient access to her very highquality care and facilitated the learning of all professionals in the clinic. Wheneverwe had very complex cases this ACNP was able to provide a comprehensiveassessment, suggest additional lab and imaging tests, formulate diagnoses andmake recommendations regarding treatment to the family physician or me. She wasalso able to make a timely phone call to the Respirology physician specialist, forfurther consultation if and when required. This allowed the most urgent patients to betriaged appropriately.• Within the Nursing Act, restrictions are placed on what the RN(EC) can ask RNs todo. An everyday example of this is the restriction which prevents RN(EC) fromordering an RN to draw a blood sample. In our clinic, a busy, inner-city CommunityHealth Centre, we have six physicians and two RN(EC) who see clients byappointment. Clients seen by the physician are often directed to the clinic RNs forvenipuncture and small procedures. This is not permitted for the RN(EC). The clinicRNs are willing and able to perform this function for us, but regulations prohibit it.This is a highly illogical restriction which impedes the smooth functioning of ourinterdisciplinary team.• I am so thankful that the College of Nurses has addressed the ACNP role anddecided to include it in the RN/EC licensure. As it stands this role isphysician/organizationally governed and places the burden of scope of practice ontothe individual nurse. This results in inconsistent practice and fragmented care for ourcancer patients.30

Appendix C: Proposed Practice Standard: Performance of Controlled Acts byNurse PractitionersIntroductionThe College’s practice standards outline the knowledge, skill and judgment necessaryfor nurses to provide safe, effective and ethical client care. Nurse Practitioners areobligated to maintain the generally accepted standards of practice of the nursingprofession as well as this practice standard. A nurse who fails to comply with a Collegepractice standard or with the generally accepted standards of practice of the professionwould be acting in a manner that is considered to be professional misconduct.This practice standard focuses on care provided by Nurse Practitioners. A NursePractitioner has advanced knowledge and decision-making skills in health assessment,diagnostics, pharmacology, health care management, community and/or programdevelopment and planning. A Nurse Practitioner can diagnose and manage the care ofclients with an acute and/or chronic physical and/or mental disease, disorder orcondition.Nurse Practitioners have the authority to initiate 5 and perform the controlled acts thatare available to members of the Extended Class. This authority is subject to the limitsand conditions outlined in the College’s Performance of Controlled Acts by NursePractitioners practice standard. When performing a controlled act, a Nurse Practitionermust practise within the limits of knowledge and experience of the specialty for whichthe Nurse Practitioner holds a specialty certificate. Nurse Practitioners will resolvesituations beyond their expertise by consulting with or referring clients to other healthcare providers.Under the Nursing Act, 1991, Registered Nurses in the Extended Class (NursePractitioner – Primary Health Care, Nurse Practitioner – Adult, Nurse Practitioner –Paediatrics, Nurse Practitioner – Anaesthesia) have access to the following controlledacts: 61. Communicating a diagnosis identifying a disease or disorder as the cause of aperson’s symptoms.2. Performing a procedure on tissue below the dermis or below the surface of a mucous5 Bolded words are defined in the glossary on page 76 The Nurse Practitioner’s ability to perform these controlled acts is subject to the conditions and limitations set out in theCollege’s Performance of Controlled Acts by Nurse Practitioners practice standard. However, this practice standard doesnot discuss the Nurse Practitioner’s ability to perform a controlled act pursuant to the delegation of that act by someonewho has the authority to delegate that act. In addition, it does not address the delegation of controlled acts by NursePractitioners. See the College’s proposed regulation Delegation for Ontario Nurses for the Nursing Act, 1991, for moreinformation.31

membrane.3. Setting or casting a fracture of a bone or a dislocation of a joint.4. Administering a substance by injection or inhalation.5. Putting an instrument, hand or finger,i. beyond the external ear canal,ii. beyond the point in the nasal passages where they normally narrow,iii. beyond the larynx,iv. beyond the opening of the urethra,v. beyond the labia majora,vi. beyond the anal verge, orvii. into an artificial opening into the body.6. Applying or ordering the application of a form of energy prescribed by the regulationsunder this Act.7. Prescribing, dispensing, selling or compounding a drug.Controlled Acts1. Communicating a diagnosis identifying a disease or disorder as the cause of aperson’s symptoms.Limits and conditionsBefore communicating a diagnosis, a Nurse Practitioner shall have:■ established a nurse-client relationship;■ performed an advanced comprehensive or focused health assessment including aphysical examination;■ ordered appropriate laboratory and/or diagnostic imaging tests and/or other testsguided by best practice evidence, safety and cost-effectiveness;■ reviewed, interpreted and documented the test results; and■ formulated a the differential diagnosis (es) and identified potential treatment options.When a Nurse Practitioner diagnoses a condition beyond the Nurse Practitioner’sexpertise to manage, the Nurse Practitioner shall contact an appropriate health careprovider for consultation and/or initiate a referral within 72 hours of communicating adiagnosis.2. Performing a procedure on tissue below the dermis or below the surface of amucous membrane.Limits and conditionsA Nurse Practitioner shall not, without consultation with a physician:■ suture wounds below the fascia;32

■ suture wounds when there is reason to believe there may be underlying damage;■ suture human or animal bites;■ suture a laceration if there is visible contamination, debris, non-viable tissue or signsof infection;A Nurse Practitioner shall not:■ perform surgical procedures outside of the Nurse Practitioner’s knowledge, skill orjudgment; or■ perform surgical procedures when the Nurse Practitioner does not have theappropriate resources to manage the potential outcomes.No Nurse Practitioner other than a Nurse Practitioner – Anaesthesia shall:■ insert and/or reposition transvenous cardiac pacemaker wires; or■ perform a cricothyrotomy.3. Setting or casting a fracture of a bone or a dislocation of a joint.Limits and conditionsA Nurse Practitioner shall not:■ set or cast a fracture that is open, displaces a growth plate/epiphysis, extends into ajoint, is a pathologic fracture, or is a fracture of an elbow, hip, pelvis or femur or;■ set or cast a fracture or dislocation where there is reason to believe that bloodvessels, ligaments, nerves or muscles are damaged or;■ reduce a displaced fracture without physician consultation.Before setting or casting a fracture of a bone or a dislocation of a joint, a Nurse Practitionershall:■ perform and document the findings of an advanced focused health assessment andphysical examination and;■ order and document the findings of diagnostic tests.4. Administering a substance by injection or inhalation.Limits and conditionsNo Nurse Practitioner other than a Nurse Practitioner –Anaesthesia or a NursePractitioner with advanced specialized knowledge, skill and judgment in this area shall:■ initiate and maintain anaesthetic techniques including general, regional and/or deepsedation during a surgical procedure; and/or■ initiate regional/deep anaesthetic blocks.Before administering anaesthesia by injection or inhalation, a Nurse Practitioner shall:■ develop and document an anaesthetic plan.A Nurse Practitioner shall:33

■ confirm (independently or in collaboration with administrators and/or qualifiedpersonnel), that processes are in place to ensure that medical equipment and devicesused by the Nurse Practitioner are serviced and maintained on a regular basis, andthat the service and maintenance is documented.5. Putting an instrument, hand or finger, beyond the external ear canal; beyondthe point in the nasal passages where they normally narrow; beyond the larynx;beyond the opening of the urethra; beyond the labia majora; beyond the analverge; or into an artificial opening into the body.Limits and conditionsNo Nurse Practitioner other than a Nurse Practitioner-Anaesthesia or a NursePractitioner with advanced specialized knowledge, skill and judgment in this area shall:■ secure and manage the airway of a client during a surgical procedure.6. Applying or ordering the application of a form of energy prescribed by theregulations under this Act. 7A. DefibrillationThere are no limits and conditions for a Nurse Practitioner applying or orderingdefibrillation.B. Transcutaneous cardiac pacingLimits and conditionsNo Nurse Practitioner other than a Nurse Practitioner-Anaesthesia shall:■ initiate transcutaneous cardiac pacing for cardiac dysrhythmias caused by anaestheticagents and/or procedures and/or surgical conditions during the perioperative period.C. Cardiac pacemaker therapyLimits and conditionsA Nurse Practitioner shall not:■ implant or perform the initial activation testing of a permanent cardiac pacemaker.D. CardioversionLimits and conditionsBefore performing a cardioversion, a Nurse Practitioner shall:■ ensure there is a physician assessment and/or consultation.E. ElectrocoagulationLimits and conditionsA Nurse Practitioner shall:■ only perform electrocoagulation in consultation with a physician.7 A future guideline will be provided by the College for support in relation to other forms of energy34

F. FulgurationLimits and conditionsA Nurse Practitioner shall:■ only perform fulguration in consultation with a physician.G. Sound wavesLimits and conditionsA Nurse Practitioner shall not:■ operate a high-frequency diagnostic ultrasound machine; or■ perform ultrasonography.7. Prescribing, dispensing, selling or compounding a drug.A. PrescribingA Nurse Practitioner prescribes drugs. 8(Standardize all Limits and Conditions for Controlled Act #7)Limits and conditionsA Nurse Practitioner shall only prescribe a drug:■ for clients with whom a nurse-client relationship is established and documented.A Nurse Practitioner shall not:■ self-prescribe a drug; or■ prescribe a drug for a family member.Before prescribing a drug, a Nurse Practitioner shall:■ utilize medication reconciliation principles in an effort to prevent errors.A Nurse Practitioner who prescribes a drug shall:■ comply with federal and provincial legislation;■ provide either a written or verbal prescription when necessary;■ document the drug prescribed; and■ provide information about the drug for the client and/or client representative.After prescribing a drug, a Nurse Practitioner shall:■ monitor and document the client’s response to the drug therapy until the client isdischarged from the Nurse Practitioner’s care;■ continue, adjust or withdraw the drug therapy, depending on the client’s response; and■ consult with an appropriate health care provider when the client’s response to the drugtherapy is other than the Nurse Practitioner anticipated.When a Nurse Practitioner continues drug therapy initiated by another health care8 Nurse Practitioners are not authorized to delegate prescribing drugs. Please refer to the College’s proposed regulationDelegation for Ontario Nurses.35

provider, the Nurse Practitioner shall:■ provide ongoing assessment;■ monitor the client’s response to the drug therapy;■ adjust dosage of the drug therapy, when appropriate; and■ consult with an appropriate health care provider, when appropriate.B. DispensingA Nurse Practitioner dispenses drugs in situations in which there are client accessbarriers.Limits and conditionsA Nurse Practitioner shall dispense drugs in accordance with federal and provinciallegislation. 9A Nurse Practitioner shall:■ only dispense drugs for clients the Nurse Practitioner reasonably believes would havedifficulty accessing the drug as a result of one or more of the following:a) not having health insurance;b) not having access to drug benefit programs;c) not having reasonable access to a pharmacy; and/ord) limited financial resources.A Nurse Practitioner who dispenses a drug shall:■ ensure either a written or verbal prescription is provided; and■ document the drug dispensed and the rationale for dispensing in the client record.C. SellingA Nurse Practitioner sells drugs in situations in which there are client access barriers.Limits and conditionsA Nurse Practitioner shall only sell drugs to clients that the Nurse Practitionerreasonably believes would have difficulty accessing the drug as a result of:■ not having reasonable access to a pharmacy; or■ the inability to pay the fees associated with the dispensing of the drugs by apharmacy.A Nurse Practitioner shall not sell:■ a drug that is defined as a “controlled substance” in the Controlled Drugs andSubstances Act, 1996, (Canada).A Nurse Practitioner who sells a drug shall:9 Nurse Practitioners are not authorized to dispense drug samples unless delegated by an authorized regulated healthcare practitioner. Please refer to the College’s proposed regulation Delegation for Ontario Nurses.36

■ do so in accordance with federal and provincial legislation;■ ensure there is a written prescription for each drug sold; and■ document the transaction and rationale for selling drugs in the client record each timea drug is sold.D. CompoundingA Nurse Practitioner compounds drugs in situations in which there are client accessbarriers.(Define Compounding in Glossary)Limits and conditionsA Nurse Practitioner shall only compound drugs that are non-sterile topical creams.A Nurse Practitioner shall only compound drugs for a client that the Nurse Practitionerreasonably believes would have difficulty accessing the drug as a result of one or moreof the following:■ not having health insurance;■ not having access to drug benefit programs;■ not having reasonable access to a pharmacy; or■ having limited financial resources.A Nurse Practitioner shall not compound drugs:■ that are defined as “controlled substances” in the Controlled Drugs and SubstancesAct, 1996, (Canada).A Nurse Practitioner who compounds drugs shall:■ do so in accordance with provincial and federal legislation;■ ensure there is a written prescription for each drug compounded; and■ document in the client record the compounding process including the name andquantity of each drug and include the rationale for compounding.GlossaryThis glossary defines terminology that is used throughout this practice standard. Many ofthese words have specific meanings in legislation, and their meanings can differ from thegeneral understanding of the words in everyday use.Consultation. A collaborative decision-making process used to enhance client care. Inthis process, the individual parties are responsible for mutual goal setting, authority, andactions and outcomes. It may be used to express opinions and recommendations; anopinion, recommendation and concurrent intervention; or to request that another healthcare provider assume primary responsibility for the care of the client (transfer of care).Cricothyrotomy. An emergency surgical airway procedure involving an incisionbetween the cricoid and thyroid cartilages in the midline of the anterior neck.37

Delegation. A formal process that transfers authority from a regulated healthprofessional who has the legislative authority and competence to perform a controlledact, to another person.Diagnostic imaging tests. These tests include X-rays, scans and ultrasounds.Electrocoagulation. Coagulation of tissue by means of a high-frequency electriccurrent. 10Fulguration. Destruction of tissue by means of long, high-frequency, electric sparks. 119Initiation. The independent decision that a specified procedure or action is required. Maybe limited by other legislation such as the Public Hospital Act Regulation 965.Limits and conditions. Criteria that a Nurse Practitioner must adhere to whenperforming controlled acts.Medication reconciliation. The process of comparing a client’s medication prescriptionsto all of the medications that the client has been taking. Reconciliation is done to avoiderrors such as omissions, duplications, dosing errors and drug interactions. 12Nurse-client relationship. A professional relationship established and maintained bythe nurse that is the foundation for providing nursing services that contribute to theclient’s health and well-being. The relationship is based on trust, respect, empathy,professional intimacy and the appropriate use of the nurse’s inherent power.Order. Can be a written or oral (for example, by telephone) client-specific instruction fora procedure, treatment, drug and/or intervention.Primary health care. An approach to health and a spectrum of services beyond thetraditional health care system. It includes all services that play a part in health, such asincome, housing, education and environment. Primary care is the element withinprimary health care that focuses on health care services, including health promotion,illness and injury prevention, and the diagnosis and treatment of illness and injury. 13Specialty certificate. The term “specialty” is used to describe a regulatorysubcategorizaton of an existing certificate. This certificate refers to members registeredin the Extended Class who are: NP-Primary Health Care, NP-Adult, NP-Paediatrics andNP-Anaesthesia.10 Venes, 2005)11 Venes, 2005)12 (Joint Commission on Accreditation of Healthcare Organizations, 2006)13 (Health Canada, 2006)38

ReferencesHealth Canada. (2006). About primary health care. Retrieved August 30, 2006, fromhttp://www.hc-sc.gc.ca/hcs-sss/prim/about-apropos/index_e.htmlJoint Commission on Accreditation of Healthcare Organizations. (2006, January 25).Using medication reconciliation to prevent errors. Sentinel Event Alert, 35. RetrievedAugust 30, 2006, fromhttp://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_35.htmVenes, D. (Ed.). (2005). Taber’s cyclopedic medical dictionary (20th ed.). Philadelphia,PA: F.A. Davis.Suggested ReadingCanadian Nurses Association. (2005). Canadian nurse practitioner core competencyframework. Ottawa, ON: Author.39

Appendix D: Proposed Regulation – Delegation of Controlled Acts1. No member may delegate a controlled act or accept a delegation and perform acontrolled act unless permitted by this regulation.Accountability2. (1) A member who delegates the performance of a controlled act is accountable for thedecision to delegate that authority.(2) A member who performs a controlled act pursuant to authority delegated to the memberis accountable for the decision to perform the controlled act as well as for theperformance of the controlled act.Delegation of a Controlled Act3. (1) Subject to subsection (3),(a) a member holding a general, special assignment or transitional class certificate ofregistration as a registered nurse or a registered practical nurse may delegate theperformance of an act authorized to the member pursuant to clause 5(1)(a) or (b) of theAct; and(b) a member holding an extended class certificate of registration as a registered nursemay delegate the performance of an act authorized to the member pursuant to section5.1 of the Act other than the authorized acts ofi. prescribing a drug; orii. ordering the application of a form of energy prescribed under the RegulatedHealth Professions Act,1991.(2) For greater certainty, a member shall not delegate the performance of a controlled actwhich the member has been authorized to perform as a result of the delegation of thatauthority from another member or a member of another regulated health profession.(3) A member who is otherwise authorized to delegate a controlled act may do so providedthe member first ensures that all of the following conditions have been met:1. The member has the knowledge, skill and judgment to perform the procedure safely,effectively and ethically.2. The member has a professional relationship with the client for whom the controlledact is to be performed.3. The member has considered the client’s needs and best interests in determiningwhether the performance of the act by another person is appropriate.4. The member has taken reasonable steps to ensure that any safeguards andresources which would be required in order for the controlled act to be performed safelyand to manage reasonably expected outcomes would be available to the person towhom the delegation is being made.5. The member has considered whether the delegation should be subject to any40

condition in order to ensure that the controlled act is performed safely, effectively andethically.6. The member has no reason to believe that the person to whom the member isdelegating the authority to perform the controlled act is a person who is not permitted toaccept that delegation.7. Before delegating a controlled act for the first time to a person who is either amember or a member of another regulated health profession, the member is satisfiedthrough a personal evaluation that the person to whom the delegation is to be made hasthe knowledge, skill and judgment to perform that controlled act safely and effectively.8. Before delegating a controlled act for the first time to a person who is not a memberof a regulated health profession, the member is satisfied through a personal evaluationof both the person to whom the delegation is to be made and the client for whom thecontrolled act is to be performed that the person to whom the delegation is to be madehas the knowledge, skill and judgment to perform that controlled act safely andeffectively for that client.9. The member has no reason to believe that the person to whom the delegation is tobe made lacks the continuing ability to perform the controlled act safely and effectively.10. The member is satisfied that the person to whom the delegation is to be made is aperson who(a) is a member who has a professional relationship with the client for whom thecontrolled act is to be performed;(b) is another healthcare provider who has a professional relationship with the client forwhom the controlled act is to be performed;(c) is a member of the client’s household; or(d) is a person who routinely provides assistance or treatment for the client.(4) The delegation of a controlled act may be made orally or in writing.(5) A member who delegates the authority to perform a controlled act shall(a) ensure that a written record of the delegation is available in the place where thecontrolled act is to be performed prior to the performance of the controlled act;(b) ensure that a written record of the delegation or a copy thereof is placed in the clientrecord either at the time the delegation takes place or within a reasonable period of timethereafter; or(c) record in the client record particulars of the delegation either at the time thedelegation takes place or within a reasonable period of time thereafter.Accepting Delegation of a Controlled Act4. (1) Subject to subsections (2) and (4) and the terms, conditions and limitations on amember’s certificate of registration, a member holding a general, special assignment ortransitional class certificate of registration as a registered nurse or registered practical41

nurse, or an extended class certificate of registration as a registered nurse may acceptthe delegation of a controlled act.(2) A member shall not accept the delegation of a controlled act unless the persondelegating the performance of that controlled act was, at the time of the delegation, amember of a regulated health profession authorized by the health professions Actgoverning that profession to perform that controlled act.(3) For greater certainty, a member shall not accept the delegation of a controlled act from aperson who was delegated the authority to perform that controlled act.(4) A member who is otherwise permitted to accept the delegation of a controlled act mayutilize the delegated authority to perform the controlled act provided the member firstensures that all of the following conditions have been met:1. The member has the knowledge, skill and judgment to perform the procedure safely,effectively and ethically.2. The member has a professional relationship with the client for whom the controlledact is to be performed.3. The member has considered the client’s needs and best interests in determiningwhether the performance of the act by the member is appropriate.4. The member is satisfied that there are sufficient safeguards and resources availableto ensure that the controlled act can be performed safely and to manage any reasonablyexpected outcomes.5. The member has no reason to believe that the person who delegated the authority toperform the controlled act is a person not permitted to delegate that authority.6. Where the delegation is subject to any conditions, the member has ensured that theconditions have been met.(5) A member who is delegated the authority to perform a controlled act shall record in theclient record particulars of the delegation unless(a) a written record of the delegation is available in the place where the controlled act isto be performed;(b) a written record of the delegation or a copy thereof is present in the client record; or(c) particulars of the delegation have already been recorded in the client record.5. A written record of the delegation or particulars of the delegation shall include the date ofthe delegation, to whom the delegation was made and any conditions applicable to thedelegation.42

Appendix E: Current Practice Standard for Registered Nurses in the ExtendedClassavailable from:http://www.cno.org/docs/prac/41038_StrdRnec.pdfNote: hard copies of this submission will include the full document.43

Appendix F: Interjurisdictional ReviewProvince orTerritoryNewfoundland andLabradorNova ScotiaPrince EdwardIslandLegislationIn 1997, the RegisteredNurses Act was amended toprovide for NPs. It wasfurther amended in 2001to provide for practiceprotocols. Practice protocolsfor specialties aredeveloped by employingagencies and approved by acommittee establishedunder the RegisteredNurses Act using theapproval processestablished and approvedby the Association ofRegistered Nurses ofNewfoundlandand Labrador (ARNNL)Council andthe Minister of Health andCommunity Services.The Registered Nurses Act,effective January 2, 2002,includes both RNs and NPs.Registered Nurses Act(2004) received royal assentand was proclaimed in 2006with the completion of all NPregulations under the Act.Scope of PracticeUnder the Registered Nurses Act,NPs are authorized to:• refer to a physician includingspecialists;• make and communicate a diagnosis;• order laboratory or other diagnostictests;• prescribe a drug (as prescribed inregulation or a practice protocolissuedto him or her); and• provide emergency care.The Registered Nurses Act authorizesNPs (both primary care and specialtyNPs) to:• make diagnoses of diseases,disorders or conditions andcommunicate those diagnoses toclients;• order and interpret selectedscreening and diagnostic tests;• select, recommend, prescribe andmonitor the effectiveness of certaindrugs and treatmentsP.E.I. has developed schedulesapproved by the Diagnostic andTherapeutic Committee, whichauthorizes NP authority to:• make and communicate a diagnosisunder certain conditions;• order laboratory or other diagnostic44

Province orTerritoryNew BrunswickQuébecLegislationIn July 2002, amendmentsto the Nurses Act (1984—amended in 1997 and 2002)provided the NPdefinition and practice andthe creation of the NPTherapeutics Committee.Amendments to other actsallowed NPs to do theirwork under the authority ofother acts (Pharmacy Act,Hospital Act,Radiological HealthProtection Act, etc.).Scope of PracticeQuébec’s Nurses Actincludes a clause thatrequires adoption ofregulations from both themedical and nursingregulatory bodies to definethe expanded scope ofpractice for specialized NPs.Regulations are developedcollaboratively between theOrdre des infirmières etinfirmiers duQuébec (OIIQ) and theCollège des médecins duQuébec. The regulations forthree specialties(neonatology, cardiologyand nephrology) wereapproved in 2005.Scope of Practicetests and X-rays;• prescribe drugs (as authorized inregulation or a practice protocolissued tohim or her); and• provide emergency care.According to the Nurses Act, an NPmay:• diagnose or assess a disease,disorder or condition andcommunicate the diagnosisor assessment to the client;• order and interpret screening anddiagnostic tests;Legislation and Regulation of NPsResponsibility of Provinces andTerritories 3• select, prescribe and monitor theeffectiveness of drugs; and• order the application of forms ofenergy.NPs may engage in five additionalactivities according to conditions andterms set out by regulations and foreach specialty:• prescribing diagnostic examinations;• using diagnostic techniques that areinvasive or entail risks of injury;• prescribing medications and othersubstances;• prescribing medical treatment; and• using techniques or applying medicaltreatments that are invasive or entailrisks of injury.Manitoba Manitoba’s Registered RNs who meet the requirements in the45

Province orTerritorySaskatchewanAlbertaLegislationNurses Act was proclaimedin 2001 as new legislation.The new ExtendedPractice Regulation wasapproved on March 22,2005 and came into forceon June 15, 2005.Amendments to theSaskatchewan RegisteredNurses Act were proclaimedon May 1, 2003 to includeNPs.Health Professions Actproclaimed in 2000 and theRegistered NursesProfession Regulation, Alta.Reg. 232/2005 wasproclaimed in November2005 and included specificregulations for NPs.Scope of PracticeExtended Practice Regulation havethe authority to includethe following services in their scope ofpractice:• assessment and diagnosis of clienthealth/illness status;• ordering and receiving results ofscreening and diagnostic tests;• prescribing drugs; and• performing minor surgical andinvasive procedures.These amendments now allow thoselicensed as a registered nurse (nursepractitioner) (RN[NP]) to:• order, perform, receive and interpretreports of screening and diagnostictests that aredesignated in the bylaws;• prescribe and dispense drugs inaccordance with the bylaws;• perform minor surgical and invasiveprocedures that are designated in thebylaws; and• diagnose and treat common medicaldisorders.Under the regulations specific to nursepractitioners the following additionalrestricted activities when practising asa nurse practitioner may beperformed:(a) to prescribe a Schedule 1 drugwithin the meaning ofthe Pharmaceutical Profession Act;(b) to prescribe parenteral nutrition;(c) to prescribe blood products;(d) to order and apply any form ofionizing radiation inmedical radiography;(e) to order any form of ionizingradiation in nuclearmedicine;(f) to order non-ionizing radiation in46

Province orTerritoryBritish ColumbiaLegislationNurses (Registered) andNurse PractitionerRegulation was approved bythe BC government onJune 28, 2005 and cameinto effect on August 19,2005.Scope of Practicemagnetic resonanceimaging;(g) to order or apply non-ionizingradiation in ultrasoundimaging, including any application ofultrasound to a9fetus;(h) to prescribe diagnostic imagingcontrast agents;(i) to prescribe radiopharmaceuticals,radiolabelledsubstances, radioactive gases andradioaerosols.In addition, NPs may distribute drugswhen a pharmacist is not available(CARNA, Prescribing and DistributingGuidelines for Nurse Practitioners,March 2004, effective November,2005 – www.nurses.ab.ca)Under the Nurses (Registered) andNurse Practitioner Regulation, NPsare authorized to:• make and communicate diagnosesidentifying disease, disorder orcondition;• order X-ray and ultrasound (definedby CRNBC standards, limits,conditions);• prescribe and dispense drugs(defined by CRNBC standards, limits,conditions);• set and cast closed simple fracturesor reduce dislocated joint (CRNBCapproved certificationrequired under CRNBC standards,limits and Conditions) and• Apply X-ray for diagnostic or imagingpurposes, except CT (CRNBCapproved certificationrequired under CRNBC standards,limits and Conditions).47

Province orTerritoryLegislationThe Nursing Profession Actof the Northwest Territoriesand amendments to theNunavut NursingProfession Act wereproclaimed January 1, 2004Scope of PracticeThe Nursing Profession Act(Northwest Territories) provides thefollowing:• to make a diagnosis identifying adisease, disorder or condition;• to communicate a diagnosis to aclient;• to order and interpret screening anddiagnostic tests;• to prescribe a drug (as prescribed inregulation or a practice protocolissued tohim or her); and• to perform other procedures that areauthorized in guidelines approved bythe minister.48

Appendix G: Statutes and Regulations – Other Canadian JurisdictionsNote: Hardcopies of this submission will include printed copies of these materials.Newfoundland & LabradorRegistered Nurses Act (2001)http://www.hoa.gov.nl.ca/hoa/statutes/r09.htm#11_1NP Regulationshttp://www.hoa.gov.nl.ca/hoa/regulations/rc980065.htmARNNL Bylawswww.arnnl.nf.ca/PDF/By_Laws_2007.pdfNewfoundland and Labrador Pharmacy Board Position Regarding Nurse PractitionerPrescribing and Pharmacist's Responsibilitieshttp://www.arnnl.nf.ca/PDF/Betty/NLPhB_Board_Position_Regarding_NP_Prescribing_Final_Version_April%2007.pdfNova ScotiaRegistered Nurses Act (2001)http://www.gov.ns.ca/legislature/legc/statutes/regisnur.htmRegistered Nurses Regulationshttp://www.gov.ns.ca/just/regulations/regs/rnregs.htmStandards of Practice for Nurse Practitioners (2005)http://www.crnns.ca/documents/CRNNS%20Standards%20of%20Practice%20Nurse%20Practitioners%20Sept%202005.pdfPrince Edward IslandRegistered Nurses Acthttp://www.gov.pe.ca/law/statutes/pdf/R-08-1.pdfNurse Practitioner Regulations (2006)http://www.canlii.org/pe/laws/regu/2006r.91/20060310/whole.htmlNew BrunswickNurses Act (Revised 2002)http://www.nanb.nb.ca/pdf_e/Publications/General_Publications/NursesAct_E&F.pdfBylaws (June 2, 2005)http://www.nanb.nb.ca/pdf_e/Publications/General_Publications/BylawsJune2005E.pdf49

Competencies and Standards of Practice for Nurse Practitioners in Primary Health Care(2002)http://www.nanb.nb.ca/pdf_e/Publications/General_Publications/CompetenciesStandardsPracticeNP2.pdfNurse Practitioner Schedules for Ordering: X-rays, ultrasounds; other forms of energy;,laboratory & other tests; and drugs (Revised 2006)http://www.nanb.nb.ca/pdf_e/Publications/General_Publications/NPSchedulesE.pdfQuébec (NOTE: I can not locate the NP Regulations in English)Nurse Act (2005)http://www.canlii.org/qc/laws/sta/i-8/20070717/whole.htmlManitobaThe Registered Nurses Act Extended Practice Regulation (2005)http://www.crnm.mb.ca/downloads/extended_practice_regulation.pdfSpecified Drugs Regulation, Man. Reg. 6/95(NOTE: RN(EP) have authority under the Extended Practice Regulations to prescribeany drug or device listed in Part 1 or 2 of the Specified Drugs Regulation under thePrescription Drugs Cost Assistance Act and other drugs listed in Schedule B of theRN(EP) Regulations)http://www.canlii.org/mb/laws/regu/1995r.6/20070717/whole.htmlStandards of Practice for Registered Nurses on the Extended Practice Registerhttp://www.crnm.mb.ca/downloads/rn(ep)standards_web.pdfCompetencies for the Registered Nurse (Extended Practice), RN(EP) Registerhttp://www.crnm.mb.ca/downloads/rn(ep)competencies_web.pdfSaskatchewanRegistered Nurses Act (1988; Amended 2003)(NOTE: Section 24 (3) pertains to NP practice)http://www.qp.gov.sk.ca/documents/English/Statutes/Statutes/R12-2.pdfSRNA Bylaws (2006)(NOTE: Bylaw VI, Section 3)http://www.srna.org/nurse_resources/srna_bylaws.pdfDrug Schedules Regulations (1997) (NOTE: NPs see Section 9.2)http://www.qp.gov.sk.ca/documents/English/Statutes/Statutes/R12-2.pdfSRNA: RN(NP) scope of practice and the lawhttp://www.srna.org/nurse_practitioner/documents/2005_RNNP_scope_of_practice.pdf50

Registered Nurse (Nurse Practitioner) RN(NP) Standards & Core Competencies (2003)http://www.srna.org/nurse_practitioner/documents/nurse_competencies.pdfSaskatchewan Registered Nurses’ Association Orientation for RN(NP)s: The laws theyapply to RN(NPs)http://www.srna.org/nurse_practitioner/documents/2004_orientation_information.pdfAlbertaAlberta Health Professions Act – Schedule 24 Registered Nurseshttp://www.health.gov.ab.ca/professionals/healthcarepro.htmlNurse Practitioner Regulations (2002)http://www.canlii.org/ab/laws/regu/2002r.126/20040901/whole.htmlCollege and Association of Registered Nurses of Alberta (CARNA) Bylawshttp://www.nurses.ab.ca/Carna-Admin/Uploads/CARNA%20bylaws_1.pdfPrescribing and Distributing Guidelines for Nurse Practitioners - (March 2004)http://www.nurses.ab.ca/Carna-Admin/Uploads/Prescribing%20and%20Distributing%20for%20NPs.pdfBritish ColumbiaHealth Professions ActNURSES (REGISTERED) AND NURSEPRACTITIONERS REGULATION[includes amendments up to B.C. Reg. 128/2006, May 12, 2006]http://www.qp.gov.bc.ca/statreg/reg/H/HealthProf/233_2005.htmNP Practice Standardshttp://www.crnbc.ca/downloads/424.pdfhttp://www.crnbc.ca/downloads/431.pdfhttp://www.crnbc.ca/downloads/430.pdfPharmacists, Pharmacy Operations and Drug Scheduling ActDRUG SCHEDULES REGULATION[includes amendments up to B.C. Reg. 303/2003]http://www.qp.gov.bc.ca/statreg/reg/P/Pharmacistsetc/9_98.htmNorth West Territories & NunavutNursing Profession Act (2003; Amended April 2007)http://www.canlii.org/nt/laws/sta/2003c.15/20070717/whole.html51

Pharmacy Act (2006; in force April 2, 2007) (NOTE: See Sections 20 (1) a (v) & 20 (1) dand Section 49.1 related to amendments to Nursing Profession Act and the acts ofdispensing compounding and selling drugs)http://www.justice.gov.nt.ca/PDF/ACTS/Pharmacy.pdfRegistered Nurses Association of NWT / NU Prescriptive authority guidelines for NWTPHCNPshttp://www.rnantnu.ca/Portals/0/Documents/Registration%202007/NP%20Application/07_04_Prescriptive_Authority_Guideline_March_30_Signed.pdfPractice Guidelines for PHCNPshttp://www.rnantnu.ca/Portals/0/Documents/npguidelines2005.pdfEntry Level Competencies for PHCNPshttp://www.rnantnu.ca/Portals/0/Documents/Registration%202007/NP%20Application/NWTRNA_ENTRY_LEVEL_COMPETENCIES_FOR_NPs_June_2000.pdfNOTE: Ontario and Yukon (no NP regulation) excluded from this review.52