Registed Nurses' Association of Ontario

Draft Revised NP Practice Standard (College of Nurses of Ontario)

Draft Revised NP Practice Standard (College of Nurses of Ontario)

As the professional association representing registered nurses, nurse practitioners (NP), and nursing students in Ontario, we are pleased to provide the College of Nurses of Ontario (CNO) with feedback on the draft revised NP practice standard. This document is an important tool for NPs, other health professionals, and the public to understand the standard of services expected from an NP.

While RNAO appreciates the College’s attempt to simplify the standard to make it easier to apply in a variety of practice settings, we take a cautious approach in assessing the condensed standard. In the proposed new standard, the appendices which included practice tools and specific guidance are removed (e.g. Decision Tree for NPs: Deciding to Perform a Controlled Act). As we articulated to CNO in November 2014 when delivering feedback on the draft revised medication practice standard, ensuring supporting resources and sufficient content are essential to effectively facilitate awareness of professional standards. We therefore invite CNO to take a leading role in partnership with RNAO to develop supporting/complementary resources such as fact sheets, webinars, and diagrams that can be used by clinicians, educators, administrators and researchers to clearly understand and interpret the standard.

In addition, we are pleased to offer the following suggestions:

  1. The draft standard defines the NP in terms of their authorization to “… diagnose, order and interpret diagnostic tests, and prescribe medication and other treatment” (lines 15-16). These are important functions of the NP role that should be emphasized. However, they should not be the sole descriptor for the NP role. This is especially relevant given the government’s clear agenda to expand the scope of the RN to include independent prescribing. The application of independent RN prescribing will be distinct from the practice of the NP. RNAO thus recommends that CNO begin to incorporate language that recognizes the distinctions between an expanded RN scope and the NP role.
  2. It is disappointing to see that the CNO no longer registers NPs in the anaesthesia category (lines 19-22). It is unclear why this important role has been stalled, especially given the invaluable contributions that these NPs could bring to palliative/end-of-life care, pain management, pre/intra/post operative care. RNAO urges the CNO to immediately reinstate this important role.
  3. RNAO is concerned to see that both ordering electrocardiograms and spirometry are not included under the tests that NPs are authorized to order (lines 42-48). This is inconsistent with what is currently on the College’s website. These are important tests for NPs to deliver comprehensive, safe and effective services.
  4. One of the stated intentions for the revised practice standard is a broader application across practice settings. However, we have identified a number of instances where the language is tilted towards illness care. For example, “This clinical practice must include advanced nursing knowledge and decision-making skill in health assessment, diagnosis and therapeutics in the treatment of clients appropriate for the NP’s specialty certificate” (lines 56-58). This would not necessarily describe the role of NPs practising in health promotion programs whereby “diagnosis” nor “treatment” are used because the focus is on upstream preventative measures that may involve prophylactic prescribing.
  5. NPs are authorized to complete a variety of legal certificates and forms and would benefit from having guidance on their accountabilities associated with doing so.

Lastly, RNAO wants to raise a number of scope of practice barriers that are still facing NPs in Ontario. Note that this list is not exhaustive, however, it is meant to highlight a number of barriers that are inconsistent with the role of the NP and impede the standard of care expected by NPs in a various settings:

  • Authority to prescribe all controlled drugs and substances: RNAO urges swift action to remove this regulatory barrier, which will allow NPs to provide comprehensive care in key areas such as end-of-life care including palliative care and medical assistance in dying, pain management, addiction, harm reduction, mental health, and hormone treatment for transgender clients.
  • Point- of- care testing: It is well within NP competency to perform and order point-of-care testing, and RNAO urges for an immediate change to regulation to grant NPs this authority.
  • Ordering electrocardiograms: NPs are authorized to order ECGs in non-urgent situations only. However, in order to increase timely access to necessary care, NPs need authority to order this test in all situations, including those that are urgent. This gap leads to decreased access to a necessary test for clients, as well as the need for inefficient medical directives.
  • Ordering physical restraints: While NPs, and all health professionals, must work to minimize restraint use and follow best practice guidelines, there are times when clients may be at risk of harming themselves or others, and restraints are necessary for safety. It may create an unsafe situation if NPs cannot provide the order for restraints.
  • Ordering diagnostic imaging: RNAO urges that NPs be immediately authorized to order all x-rays, CT scans, and MRIs.
  • Providing Mental Health Services: One in five Canadians in any given year experiences a mental health or addiction challenge. There are significant gaps in care for Ontarians experiencing a mental health challenge. NPs are assuming the roles of most responsible providers, however, the Mental Health Act does not authorize them to provide essential services. For example, they cannot apply for psychiatric assessments.

Anne, RNAO is a trusted partner and has worked with CNO for many years to champion the NP role in Ontario through safety, effectiveness and quality. We look forward to this feedback being incorporated in the final version of the revised NP Practice Standard.

Warm regards,

Doris Grinspun, RN, MSN, PhD, LLD(hon), O.ONT.
Chief Executive Officer
Registered Nurses' Association of Ontario

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