Independent RN Prescribing
One of the best ways to improve access to care is to grant registered nurses (RN) the authority to prescribe medications independently. This is something that RNAO has been calling for since 2012.
At RNAO's 2015 Queens Park Day (QPD), Ontario's Minister of Health Eric Hoskins and Premier Kathleen Wynne officially committed to expanding the RN scope of practice to include prescribing, and last week at RNAO's 2016 QPD the Minister said he is soon moving forward with RN prescribing. Members -- RNs, NPs and nursing students -- urged the Minister to move with Independent RN Prescribing.
The Minister is waiting for recommendations from the Health Professions Regulatory Advisory Council (HPRAC). This is because a few months ago, the Minister directed HPRAC to consider three models for RN prescribing and provide an implementation recommendation by March 31, 2016. The three models are defined by the MOHLTC as:
- Independent prescribing: In this model, a nurse may prescribe medications, under their own authority, without restrictions or from a limited or pre-defined formulary within a regulated scope of practice. Independent prescribers are allowed to prescribe any licensed or unlicensed drugs that are within their clinical competency area. As an independent prescriber, the RN would be fully responsible for the assessment of the patient’s needs and prescription of medication.
As an independent prescriber, an RN would be similar to a physician in terms of ability to prescribe. However, an RN would not have access to prescribing controlled drugs and substances.
- Use of protocols: In this model, written instructions allow RNs to supply and administer medications within the terms of a predetermined protocol. The use of protocols is used for the supply and administration of named medicines in an identified clinical situation. RNs are only able to supply and administer medications within the strict terms of the predetermined protocol. An RN under this model is responsible for the acceptance of the protocol but the prescribing physician or regulated health professional with prescribing authority* is responsible for the assessment of the patient’s needs and prescription of any medication.
Through the use of protocols, an RN would be able to prescribe specific medications under specific circumstances, similar to how RNs currently prescribe through the use of an order or a medical directive.
- Supplementary prescribing: Supplementary prescribing is a hybrid of independent prescribing and use of protocols. This model involves a partnership between a RN, physician and patient, where after an initial assessment of the patient’s needs by the physician, a nurse may prescribe medication. In this model, a patient-specific clinical management plan (CMP) is developed by the nurse and physician that allows the nurse to prescribe within a limited or pre-defined formulary or by class of drugs within their clinical competency area. The collaborating physician shares the responsibility of prescribing and holds full responsibility for the assessment of a patient. There are no restrictions on the type of patient condition or patient population that a CMP could be developed for between a physician and RN.
As a supplementary prescriber an RN, working within a previously established CMP, would be permitted to prescribe for a variety of patient clinical conditions as long as they are within the RN’s clinical competency.
*Please note: for the purposes of the models outlined above, physician and regulated health professionals with prescribing authority include nurse practitioners or any other appropriate non-physician prescriber.
Timely access to quality patient care, health system effectiveness, professional accountability, and continuity of care – these are the reasons why RNAO is advocating for an independent model of RN prescribing, along with the ability for RNs to order diagnostic testing and communicate a diagnosis to provide care. There are over 96, 000 RNs working in diverse roles, sectors and regions across Ontario. The implementation of an enabling legislative and regulatory framework will set the foundation for the expanded scope of RN practice to meet the needs of people.
Placing restrictions on the expanded scope of practice (i.e. prescribing lists or collaborative practice agreements) at the legislative level will diminish capacity at all other levels (regulatory, employer and nurse) to effectively implement RN prescribing.
Moving forward with supplementary or protocol models of RN prescribing wouldn't result in the kind of change Ontarians need, nor the transformational and bold health system improvements that the ministry is looking for when it comes to its health-care transformation plan. For example, vulnerable populations will not be able to maximize their contact with the health system, patients will still be waiting for access to primary care, the ability to intervene early in acute and home care will be reduced, and residents in long-term care will still experience unnecessary transfers to the emergency department. In effect, it would mean the status quo. In both models, physicians or NPs would have to assess the client and authorize treatments. This ultimately restricts access to care and decreases health system effectiveness through: blurred accountability between physicians or NPs authorizing medications and RNs prescribing them, increased duplication of services, fragmented care, and an inability to address patients’ unique needs in a timely manner.
RNAO wants independent RN prescribing to be voluntary for current RNs who choose to pursue the necessary continuing education (proposed at this time as 300 hours course). We expect this expanded scope of practice to be integrated into the baccalaureate nursing curriculum by 2020.
For more details about RNAO’s position supporting independent RN prescribing, please review the downloadable files below.