Policy and Political Action

Policy & Political Action

RNAO Submission on RN Prescribing – Proposed Regulation Changes

Summary of RNAO Recommendations

Recommendation 1. The College of Nurses of Ontario (CNO) enables independent RN prescribing by:
a) Specifying under regulation 17. (1) that an RN in the General class is authorized to prescribe any medication for the treatment of non-complex health conditions within their clinical competency area, with the exception of controlled drugs and substances.
b) Removing “Schedule 4 Individual drugs and categories of drugs that may be prescribed” and all references to a schedule.
c) Adding the authority for RNs to order and where appropriate perform diagnostic testing, inclusive of laboratory testing and point-of-care testing.

Recommendation 2. CNO include an additional clause under 17. (6) that education approved by Council to educate RNs in prescribing medications may be independent of or part of the education and training required to become an RN.

Recommendation 3. Indicate on the public Find-a-Nurse register that an RN has met CNO’s requirements to prescribe medication by including the notation the nurse is “authorized to prescribe”.

Introduction

The Registered Nurses’ Association of Ontario (RNAO) is the professional association representing registered nurses (RN), nurse practitioners (NP), and nursing students in all settings and roles across Ontario. Since 1925, RNAO has advocated for healthy public policy, promoted excellence in nursing practice, increased nurses’ contributions to shaping the health system, and influenced decisions that affect nurses and the public they serve.

RNAO welcomes the opportunity to provide feedback to the College of Nurses of Ontario (CNO) on the proposed regulation changes under the Nursing Act, 1991 to expand scope of practice to enable RN prescribing.

RNAO has called for an expanded RN scope of practice for many years – inclusive of independent RN prescribing – and supports regulation changes to enable independent RN prescribing. Following amendments to the Nursing Act in 2017 authorizing RNs to communicate a diagnosis for the purpose of prescribing and to prescribe medication designated in the regulations, CNO was directed to take the necessary steps to enable these changes in RN scope of practice. RNAO is disappointed in the overly restrictive approach taken by CNO in developing the framework to enable RN prescribing. CNO’s proposed regulation changes are limited, and will do little to increase access to care for people and increase efficiencies in our health system.

RNAO supports independent RN prescribing as the best model to implement this expanded scope of RNs. In the independent RN prescribing model, an RN may prescribe medications under their own authority within a regulated scope of practice, without restrictions from a limited medication schedule. Independent prescribers are allowed to prescribe any medication that is within their clinical competency area, with the exception of controlled drugs and substances. As an independent prescriber, an RN would be fully responsible for the assessment of a patient’s needs and prescription of medications.

The independent prescribing model recognizes the broad depth of RN expertise, and ensures RNs are fully accountable for their own practice. In Ontario, RNs are autonomous health professionals who practise independently and collaboratively within interprofessional teams. RNs enter practice with knowledge of pharmacology, immunology, microbiology, anatomy, physiology, pathophysiology, epidemiology, genetics, and nutrition. RNs are proficient in interpreting and applying evidence in their practice, and will approach independent prescribing in the same manner.

The independent RN prescribing model has been successfully implemented in other jurisdictions, providing an opportunity to increase the public’s access to safe and comprehensive care. In jurisdictions where RNs practise to an independent expanded scope, clients have same day or next day appointments in primary care, increased continuity of care and caregiver, improved chronic disease management (i.e., refilling prescriptions), increased access to care for vulnerable populations (i.e., homeless clients with communicable illnesses) and timely access to care for those living in rural or remote areas.

With more than 100,000 RNs registered to practise with the CNO, RN prescribing has huge potential to increase access to care across Ontario in all practice settings. The greatest impact for this expanded scope is likely to be realized in community, home and long-term care settings, such as by securing same day access in primary care and decreasing transfers from nursing homes to emergency departments. There is also potential to better reach patients in the most rural and remote areas of Ontario by ensuring RNs working in remote outpost nursing stations are not barred from practising to this expanded scope. The exclusion of any sector deprives Ontarians from timely access to care, and discriminates against RNs who voluntarily want to take on this expanded scope.

The risk of harm to patients by independent RN prescribing is minimal. As regulated health professionals, RNs are required to be aware of their competency level and practise within it. CNO provides RNs with practice supports, including standards for Decisions About Procedures and Authority and Medication. The Decisions About Procedures and Authority standard outlines expectations when determining if nurses have the authority to perform a procedure, if it is appropriate for them to perform that procedure, and if they have the competency to perform the procedure. The Medication standard is being updated to outline professional accountabilities of RN prescribers. Additional practice supports are also being developed to support this expanded scope, including competencies for RN prescribing and CNO approved education.

Independent RN prescribing

CNO’s proposed regulation changes specify a limited list of drugs and drug categories that RNs would be permitted to prescribe under Schedule 4.

The restrictive approach of CNO limits the potential of RN prescribing to increase timely access to care to Ontarians. This is a wasted opportunity to incorporate learning from other jurisdictions with experience in safely implementing RN prescribing. The experience in the United Kingdom (UK) in particular is one we should learn from. The UK began implementing RN prescribing in 1998, initially through a model with a limited formulary. An evaluation in 2005 found the use of limited lists of drugs was restricting the benefit of RN prescribing to patients and to health system efficiency. The experience of updating the formulary was also found to be a long and resource intensive process. The next year, the UK removed unnecessary restrictions to pursue independent prescribing. The model of independent RN prescribing has now been successfully used in the UK for over 12 years. Indeed, restricting RN prescribing with lists of drugs and drug categories creates unnecessary regulatory measures and presents barriers to clients accessing care.

The proposed Schedule 4 in the regulation changes by CNO restricts the practice of RNs to prescribe, and will require an ongoing resource intensive process to review and expand the list of drugs and drug categories. RNAO urges CNO to enable independent RN prescribing by specifying in the regulations that RNs are authorized to prescribe any medication for the treatment of non-complex health conditions within their clinical competency area, with the exception of controlled drugs and substances.

RNAO recognizes a major limitation to enabling independent RN prescribing in Ontario is that the legislation as currently written does not give RNs the authority to order diagnostic testing. RNAO calls for the necessary legislation to be amended to allow RNs to order and where appropriate perform diagnostic testing, inclusive of laboratory testing and point-of-care testing. The ability to order diagnostic tests is a necessary aspect of formulating a diagnosis, part of the continuum of care necessary for safe prescribing. RNs need the authority to order and perform diagnostic tests to inform their diagnoses and appropriately prescribe medications.

Recommendation 1. CNO enables independent RN prescribing by:
a) Specifying under regulation 17. (1) that an RN in the General class is authorized to prescribe any medication for the treatment of non-complex health conditions within their clinical competency area, with the exception of controlled drugs and substances.
b) Removing “Schedule 4 Individual drugs and categories of drugs that may be prescribed” and all references to a schedule.
c) Adding the authority for RNs to order and where appropriate perform diagnostic testing, inclusive of laboratory testing and point-of-care testing.

Education to support RN prescribing

CNO’s proposed regulations outline that RN prescribing is conditional on the RN successfully completing education approved by Council. RNAO supports this condition, as captured in 17. (6):
“A member who is a registered nurse in the General Class shall not prescribe any drug unless the member, (a) has successfully completed education approved by Council that was specifically designed to educate registered nurses to safely, effectively, and ethically prescribe drugs”

RNAO recommends including further clarification that the education may be either independent or part of the education and training required to become an RN. This aligns with RNAO’s recommended two-phase approach to the implementation of independent RN prescribing. The first phase expands the scope of currently practising RNs who choose through voluntary enrollment, to integrate prescribing into their practice. These RNs would be required to complete and pass an approved postgraduate course. The second phase would incorporate the course curriculum into baccalaureate nursing programs. RN prescribing competencies would be reflected in RNs’ entry-to-practice exam and become part of entry-to-practice requirements moving forward. To support this phase, RNAO urges the inclusion of an additional clause 17. (6) (c) as outlined below:
The education mentioned in subsection (6) may be education that is either independent of or part of the education and training required to become a registered nurse.

To support the adequate preparation of the nursing workforce for this expanded scope, it is critical that CNO include educational requirements in the proposed regulation to guide the present and future practice of RN prescribing.

Recommendation 2. CNO include an additional clause under 17. (6) that education approved by Council to educate RNs in prescribing medications may be independent of or part of the education and training required to become an RN.

Communicating the RN prescribing role

CNO requested feedback on the terminology appropriate to communicate on the Find-a-Nurse register that an RN has met the College’s requirements to prescribe medication. RNAO recommends a notation be added that outlines the RN is “authorized to prescribe”.

Recommendation 3. Indicate on the public Find-a-Nurse register that an RN has met CNO’s requirements to prescribe medication by including the notation the nurse is “authorized to prescribe”.

Additional proposed changes

RNAO is pleased with how CNO has outlined regulations regarding the dispensing of medications and the administration of substances by injection or inhalation. RNAO supports the changes to ensure all nurses have the same accountabilities for dispensing medications and for administering substances by injection or inhalation.

Conclusion

RNAO strongly supports independent RN prescribing in all practice settings and inclusive of diagnostics as the best model to implement the expanded scope of RN prescribing. It is disappointing that CNO is proposing an extremely limited approach to regulating RN prescribing. CNO’s proposed regulation changes will do little to increase Ontarians’ timely access to care and increase efficiencies in our health system.

Independent prescribing allows RNs to prescribe any medication for the treatment of non-complex health conditions under their own authority within a regulated scope of practice and within their clinical competency area, with the exception of controlled drugs and substances. Independent RN prescribing has been demonstrated to have positive outcomes on access, safety, and person centred care. RNAO urges CNO to amend the proposed regulations to enable independent RN prescribing in all practice settings and inclusive of diagnostics.

Thank you for the opportunity to provide feedback on the proposed regulation changes to expand the scope of practice to enable RN prescribing.

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