CNPS – RN Prescribing

RN Prescribing


September 2017

Note:  In this document, references to dispensation of medication specifically refer to the dispensation of medication without an order by RNs who have additional authority obtained by way of certification or other official recognition, for the treatment of specific conditions following a nursing assessment.

In an effort to safely improve timely access to care for certain patient populations, an increasing number of provinces and territories have included (or are in the process of including) the ability to prescribe or dispense certain medications without an order into the scope of practice for registered nurses (RNs). This expanded scope of practice involves assessing, diagnosing and treating certain limited medical conditions by dispensing or prescribing medications. The practice is generally limited to RNs who work in specialized areas of practice or who work in a setting where additional adequate support is available from physicians or nurse practitioners.

Qualifications

RN prescribing, to date, requires formal authorization from the nursing regulator in the form of certification or advanced designation.  This formal authorization to prescribe is generally based on successful completion of approved specialized education and/or practice experience. RNs authorized to incorporate prescribing in their practice will also be expected to fulfill all continuing education or competency requirements.

Regulatory framework and support for the practice of RN prescribing

RN prescribing is generally authorized within specific parameters, related to the patient’s medical condition and its complexity, practice setting, patient population, choice of medication and ability to order screening or diagnostic tests.  These parameters are set out in regulations, standards of practice or practice directions, and/or other forms of clinical support documents (clinical or decision support tools, protocols, guidelines, explanatory guides).  Clinical support documents may also generally list the indications and contraindications of contemplated treatments, set out specific appropriate pharmacological interventions (including the specific medication, dosage, frequency, etc.), identify potential complications and follow-up, and when to consult a physician or nurse practitioner.

Courts and disciplinary committees are likely to refer to these documents to determine if an RN met the standard of care or complied with their professional obligations when prescribing or dispensing medication without an order.

RNs with additional authority to prescribe or dispense should carefully review and understand the governing regulations, standards, practice directions, and any other document intended to serve as a clinical support tool to know what content:

  • is mandatory;
  • is intended as a guideline (i.e. a description of how the RN is expected to proceed in most cases but which can, using professional knowledge and judgment, be adapted to the specific circumstances of the patient), and
  • is to be used as a clinical reference (i.e. useful information that the nurse would already be expected to know and rely upon to make decisions about patient care).

A clear understanding of the limits of the advanced authorization to prescribe or dispense medication will avoid a claim that the RN is practising outside the permitted scope of practice, and the legal risks that this could entail: disciplinary action by their regulatory body and/or their employer, as well as prosecution before the courts for the unauthorized practice of medicine or nurse practitioner practice.

Reducing clinical and legal risks associated with prescribing medication

Although the prescription of medication is expected to assist in resolving a medical condition, it can at times have known or unexpected side effects for patients. Adverse consequences have also been known to result from the wrong choice of medication, the inappropriate dosage, the medication’s interaction with other medications, or the failure to follow up on the medication’s effectiveness and continued appropriateness, among other things.  

Standards, practice directions and other clinical support documents are already likely to set out practice expectations intended to reduce these risks, including:

  1. Making adequate inquiries, doing a thorough examination, taking a proper history as well as ordering laboratory or diagnostic imaging tests to identify the pathology that requires treatment and to establish if medications are indicated
  2. Establishing that the medication is not contraindicated for the particular patient
  3. Establishing the appropriate dosage, mode and frequency of administration
  4. Obtaining the patient’s informed consent and instructing the patient about the administration of medication
  5. Monitoring the effectiveness of the medication and identifying any potential complications

The following considerations may help to further reduce the risk of clinical and legal complications.

a)     Are you making full use of your own professional knowledge, skill and judgment?

Although the standards, practice directions and other practice support tools developed by nursing regulators provide a very comprehensive framework and guide for the practice of RN prescribing, it is not possible to anticipate every possible scenario or patient presentation. RNs should continually apply their professional judgment to assess whether a proposed course of treatment is appropriate in the circumstances.

  • Is the patient’s presentation also indicative of other medical conditions? Have they been ruled out?
  • Have you conducted a medication reconciliation? Is the patient taking other medications that should be taken into account?
  • Does the patient suffer from other pathologies or conditions that should be taken into account in arriving at a diagnosis or in the choice of treatment?
  • Does the treatment of the patient fall outside your knowledge, skill and judgment?

b)     Have new standards, guidelines or medication alerts been published that should be taken into account?

Clinical knowledge is constantly evolving, and the treatment of a medical condition may need to be informed by newly revised guidelines or standards from sources recognized as authoritative in the health-care community. Manufacturers or government authorities may also advise of newly uncovered contraindications for certain medications. Are there means by which this information is brought to your attention to determine the preferred course of treatment? Would that preferred course of treatment still fall within the range of treatments permitted by the regulator? If not, should a consultation be arranged with a nurse practitioner or physician to implement a course of treatment that meets the standard of care?

c)      Are there other professional obligations, employer policies or ethical considerations that should be considered?

Other standards, guidelines, employer policies or ethical considerations may apply. For instance, an employer policy may restrict, in the employment setting, the circumstances in which an RN with additional authority to prescribe may exercise that authority. As an example of ethical considerations, RN prescribers should be familiar with guidelines on conflict of interest and the extent to which they may preclude treatment of family members and friends.

d)     Does the patient have the necessary capacity to provide an informed consent and implement the treatment?

Consider whether consent should be obtained from a substitute decision-maker and whether the patient has adequate support at home to ensure that the patient will take the medication as prescribed.

e)     During your assessment, have you identified an unrelated condition needing follow-up care of which the patient seemed unaware?

It is well-accepted that a health-care professional, to meet the standard of care, is not required to investigate conditions unrelated to the reason for the patient’s consultation. However, if, in the course of conducting an assessment, a health-care professional noted an unusual presentation or made a finding that could be indicative of a serious health condition, a court would be likely to find that the health-care professional had an obligation to alert the patient to this condition or take other reasonable steps so that an appropriate follow-up could be arranged.

f)      Has the patient been provided with adequate discharge instructions?

Canadian courts have held that patients who are returning home to implement a course of treatment should receive adequate information for self-care. This would normally include

  • the diagnosis;
  • instructions on how to implement the course of treatment and anything to avoid;
  • the duration and expected outcome of the treatment;
  • information about planned follow-up, if any;
  • the potential complications of the treatment, their implications, signs and symptoms, what to do if they should occur, and when to seek medical attention.1

g)     Are the prescription pads kept out of the reach of others?

Prescription pads should be stored in a secure location to reduce the risk of loss or theft.

 h)     Have your interactions with the patient been adequately documented?

It would be prudent to specifically include steps taken to rule out contraindications for treatment, significant risks mentioned during the discussion about informed consent as well as a summary of discharge instructions to the patient. Handouts, customized for patient needs as necessary, are an appropriate way of documenting the discussion and assisting the patient with self-care. They can also serve as a helpful legal risk-management tool if a copy is retained in the chart.2

Professional liability protection for RN prescribers

RNs with additional authority to prescribe or dispense medication, who are RN beneficiaries of the CNPS,3 continue to have access to the full range of professional liability protection and legal services of the CNPS, provided their professional practice remains within the boundaries of their authorized scope of practice.

To have a discussion about legal risks and required professional liability protection for a practice that includes authorized prescribing, please contact the CNPS.

THIS PUBLICATION IS FOR INFORMATION PURPOSES ONLY. NOTHING IN THIS PUBLICATION SHOULD BE CONSTRUED AS LEGAL ADVICE FROM ANY LAWYER, CONTRIBUTOR OR THE CNPS. READERS SHOULD CONSULT LEGAL COUNSEL FOR SPECIFIC ADVICE. IT WILL BE REVISED AND UPDATED AS NECESSARY AS RN PRESCRIBING IS INTRODUCED IN MORE PROVINCES AND TERRITORIES.



1. Georghiades v MacLeod, 2005 CanLII 14149 (ON SC)

2. See Fowlow v Gupta, 2012 ONSC 6531 (CanLII), in which the court stated, “Despite [the nurse's] lack of express recollection of the events in question, [the patient's] signature on the document is strong confirmation that he received the document and the instructions that [the nurse] says were her standard practice. […] In the circumstances, I prefer and accept [the nurse's] version of what took place when [the patient] was discharged.”

3. To confirm whether you are a CNPS beneficiary, visit www.cnps.ca/eligible.

 

 

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