Nursing Practice Updates

The number of RNs and NPs engaging in alternative or complementary therapies, such as aesthetics, through non-traditional employers or self-employed practice, has increased in recent times.  These practices require assessment by the College of Registered Nurses of Saskatchewan (CRNS) to determine if the activity is recognized as registered nursing practice. Being engaged in self-employed practice brings certain opportunities as well as inherent risks, therefore it is important for RNs and NPs interested in and/or practicing in these areas to:

• Consult with a Nursing Practice Advisor to discuss your practice situation and receive guidance on next steps;
• Consult with a Regulatory Services Nursing Advisor to discuss the Recognition of Practice process;
• Refrain from using the RN or NP title until the activity has been recognized as nursing practice by the CRNS;
• Ensure that the necessary resources, including but not limited to, supplies to manage untoward events, policy/procedure manual, are in place for safe patient care;
• Ensure that you have the appropriate authority to conduct the activities; and,
• Refrain from including hours worked in these areas in self-reported RN or NP practice hours until the activity has been recognized as nursing practice by the CRNS.

As the landscape of alternative and complementary therapies grows and changes, the CRNS applies principles of right touch regulation when working with members to reasonably assure accountable professional practice. The CRNS lives this by applying consistent and transparent processes, providing decisions that are proportionate to the risk posed and by showing agility to adapt to change while keeping the focus on public safety.

CRNS Nursing Advisors are available by emailing:

Regulatory Services at regulation@crns.ca or

Practice at practiceadvice@crns.ca.

The current Health Canada section 56 exemption for all drugs under the Controlled Drugs and Substances Act (CDSA) that was set to expire on September 30, 2021, has been extended to September 30, 2026. The purpose of the exemption was to reduce regulatory barriers to support the continuity of care for patients, and as the pandemic continues and Health Canada works toward modernizing federal regulations, the extension to September 30, 2026, meets these continued needs. The Saskatchewan Prescription Review Program partners – Ministry of Health, Saskatchewan College of Pharmacy Professionals, College of Registered Nurses of Saskatchewan, College of Physicians and Surgeons, and the College of Dental Surgeons of Saskatchewan – have considered the long-term implications of the exemption, with a focus on patient safety and access.

This exemption provides prescribers, including Nurse Practitioners, the authority to issue a verbal prescription for controlled substances drugs to extend or refill a prescription. The Saskatchewan Prescription Review Program partners have agreed to accept the new exemption with the following two provisions for Saskatchewan:

• CDSA drugs may only be transferred once within Saskatchewan. While there remains risk of diversion of medications, the Patient ID Policy alleviates some risk and permitting one transfer may benefit the patient.
• Verbal prescription orders should only be accepted after every effort has been made to receive a written or e-prescription from a provider. The rationale for accepting a verbal order must be documented by the pharmacist.

As previous, Health Canada can terminate this exemption depending on the current conditions if the Minister deems that such suspension is necessary to protect public health, safety or security. If necessary, the Minister may change the terms and conditions of this exemption. Should this be the case, you will be informed. Read the Full Statement

Industry sponsorship consists of any interest: personal; business; commercial; political; academic; or financial offered by a private, for-profit, or commercial enterprise as part of its marketing and public relations efforts. When encountering industry sponsorship, Registered Nurses (RN) and Nurse Practitioners (NP) must be aware of conflicts of interest. A conflict of interest can be an actual, perceived or potential conflict between the professional duty of an RN or NP and their private interests. A conflict of interest can occur when the RN or NP is in a position to make a decision based upon what is beneficial to their individual interests (i.e., deriving personal benefit [Traversy et al., 2021]) and not in the best interest of the client.

RNs and NPs can engage in ethical considerations for industry sponsorship to ensure safe, competent and ethical care for clients in Saskatchewan by:

• Reflecting on and practicing according to current CRNS practice documents, including:
• • The Registered Nurses Act, 1988; CRNS bylaws; CNA Code of Ethics for Registered Nurses; Registered Nurse Practice Standards; Registered Nurse Entry-Level Competencies; Registered Nurse (Nurse Practitioner) Practice Standards; Registered Nurse (Nurse Practitioner) Entry-Level Competencies; and other CRNS documents as appropriate.
• Understanding the employer’s conflict of interest policy. If a conflict of interest policy does not exist, advocate for policy that addresses conflict of interest.
• Identifying and seeking to avoid conflict of interest to ensure the maintenance of public trust.
  • Any conflict of interest must be resolved in favour of the interest of the client receiving care.
• Being fully transparent and fully disclosing any actual, perceived or potential conflict of interest when engaging in industry sponsorship.

This nursing practice update replaces the former CRNS Ethics Guidelines for Industry Sponsorship, 2015.

Questions or comments are welcome and can be directed to practiceadvice@crns.ca or by phone: 306.359.4200 or 1.800.667.9945 (toll-free within Canada).

Resources:
• RN Practice Standards
• RN Entry-Level Competencies
• CNA Code of Ethics (2017)
• Registered Nurse (Nurse Practitioner) Entry-level Competencies (ELC)s CRNS
• Registered Nurse (Nurse Practitioner) Practice Standards CRNS
• Self-Employed Practice Guideline

Reference:
Traversy, G., Barnieh, L., Akl, E. A., Allan, G. M., Brouwers, M., Ganache, I., … & Tonelli, M. (2021). Managing conflicts of interest in the development of health guidelines. CMAJ, 193(2), E49-E54.

Registered nurses (RN) are responsible and accountable to provide evidence-based, safe, competent and ethical nursing care in all practice settings. In the emergency department, “the process of triage is essential for safe and appropriate care of the emergency department patient” (National Emergency Nurses Association [NENA], 2019).

In 2019, NENA revised their position statement, Role of the Triage Nurse and includes the following key points:

• Triage is a sorting process that requires rapid assessment, critical thinking and application of a standard set of guidelines with patients that can experience instability and changes to their condition.
• The process of triage is best carried out by RNs and Nurse Practitioners (NP) with emergency nursing expertise who have completed a triage-specific educational program.

RNs and NPs work in the emergency department as part of a multidisciplinary team, where safe and appropriate care is best achieved through collaboration and respect.

This nursing practice update replaces the former Triaging in Emergency Departments CRNS and SALPN Joint Statement, 2013.

If you have questions, please contact an CRNS Practice Advisor by phone at 1.800.667.9945 or 306.359.4200 or by email practiceadvice@crns.ca

Reference:

National Emergency Nurses Association. 2019. Role of the Triage Nurse. Retrieved from https://nena.ca/w/wp-content/uploads/2014/11/Role-of-the-Triage-Nurse-2.pdf

On June 1, 2021, The Coroners Amendment Act, 2019 and The Coroners Amendment Regulations, 2021 came into force making several changes to The Coroners Act, 1999 and The Coroners Regulations, 2000. There are a couple of changes that may be important for Nurse Practitioners (NP) to be aware of with respect to the reporting of deaths resulting from medical assistance in dying (MAiD). The changes include:

1. The definition of “medical assistance in dying” as defined in section 241.1 of the Criminal Code has been moved from The Coroners Regulations, 2000 to Section 2 of The Coroners Act, 1999.

2. Subsection 7(4) has been added to The Coroners Act, 1999 which clarifies that the reporting requirements under section 7 do not apply with respect to a person who died as a result of medical assistance in dying where the underlying cause leading to death is natural, i.e. from a natural disease process.

3. Subsection 7(5) has been added which requires an NP to report a death resulting from medical assistance in dying to a coroner if the underlying cause leading to the death is unnatural, i.e. from injury rather than disease.

If you have questions, please contact an CRNS Practice Advisor by phone at 1.800.667.9945 or 306.359.4200 or by email practiceadvice@crns.ca.

The Government of Saskatchewan amended vital statistics legislation effective January 1, 2016, giving NPs the legal authority to sign the MCOD and MCOS. Information for NP practice in this area has been contained in the CRNS Guidelines for NPs Completing Medical Certificate of Death & Medical Certificate of Stillbirth, 2016. The guideline has been discontinued and this update provides the most current information and resources.

Physicians, coroners, and NPs share responsibility for proper completion of MCOD and MCOS. NPs registered with the CRNS whom have the appropriate knowledge, skills and competencies are authorized to complete a MCOD and MCOS unless the death needs to be reported to a coroner. NPs need to be familiar with the current provincial legislation that will guide their clinical decisions including;

• The Vital Statistics Regulations;

• The Vital Statistics Act;

• The Coroners Regulations; and

 • The Coroners Act.

All Government of Saskatchewan documents are available on Queen’s Printer at the following web site http://www.qp.gov.sk.ca/

Additional resources for NPs:

• Government of Saskatchewan, Vital Statistics, eHealth Saskatchewan. (2016). Guidelines for completing the medical certificate of death and medical certificate of stillbirth. Regina, SK. https://www.ehealthsask.ca/residents/deaths/Documents/HowToCmpltMCD%20v7.pdf
• CPSS 2016, Physician obligations regarding medical certification of death. https://www.cps.sk.ca/imis/CPSS/Legislation__ByLaws__Policies_and_Guidelines/Legislation_Content/Policies_and_Guidelines_Content/Physician_Obligations_Regarding_Medical_Certification_of_Death.aspx
• 2016 CRNS Webinar, edited Jan 2021 https://youtu.be/tg0EnxOPTmk
• CMPA https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2016/completing-medical-certificates-of-death-who-s-responsible

If you have any questions, please contact an CRNS Practice Advisor by phone at 1.800.667.9945 or 306.359.4227 or by email practiceadvice@crns.ca.

The College of Physicians and Surgeons of Saskatchewan (CPSS) has recently released a Guideline: Referral-Consultation Process. The guideline includes guidance for physicians who are writing referrals and consultation reports. Nurse Practitioners (NP) are included as care providers within the document. Expectations for communication to/from consulting physicians are important for NPs to know, understand and implement into their practice.

NP practice standards set the expectation for NPs to understand the roles of, and collaborate with, other health care providers to support optimal client outcomes (CRNS, 2017). Section four of the guideline outlines the expectations of referring physicians. The CRNS supports the information in this section and expects NPs to follow these guidelines when referring a patient to a specialist.

If you have any questions, please contact an CRNS Practice Advisor by phone at 1.800.667.9945 or 306.359.4227 or by email practiceadvice@crns.ca.

Reference:

College of Registered Nurses of Saskatchewan (CRNS). (2017). Registered Nurse (Nurse Practitioner) Practice Standards. Retrieved from https://www.crns.ca/wp-content/uploads/2019/05/RNNPPracticeStandards2017.pdf

As of December 1, 2020, Nurse Practitioners in Saskatchewan will no longer be required to complete 600 clinical hours to maintain eligibility for registration. According to CRNS Bylaw VI subsection 3(7), NPs are required to work in nurse practitioner activities approved by the association in one of the four specialties for at least 900 hundred hours in the three years immediately preceding application. However, there is no longer a requirement for clinical hours.

This modification was made in recognition of changes in NP practice acknowledging the increasing diversity with many NPs working in various domains of practice outside of a clinical setting.

For any questions regarding this change, please email Leah White, RN Nursing Advisor (lwhite@crns.ca)

Infection Prevention and Control Canada has released an updated document on the use, cleaning, disinfection, sterilization and storage of foot care devices. The document outlines the required equipment and devices for client treatment, as well as stipulations for the purchasing and reusing of foot care devices, and options for guaranteed sterilization of the devices if items are being reused.

It is your duty as the Registered Nurse administering care to ensure that the client is not placed at risk of infection when foot care devices are being used. The level of sterilization of foot care instruments and supplies must be at the level of a health professional. RNs should evaluate their current practices against the recommended infection prevention and control practices within the document and adjust, as necessary.

With the rise of instances of chronic diseases increasing the need for advanced foot care, this document is to ensure that all Registered Nurses with this added certification are up-to-date on the best practices for safe foot care treatment, and are educated on the options available to ensure infection does not occur.

Read the full document here.

RNs and NPs are working with organizations to provide continued safe, competent and ethical care to the people of Saskatchewan during the COVID-19 pandemic. Using virtual means, such as telehealth, to connect with patients and families is a necessity in today’s environment. Telehealth connects patients and health care providers who provide health services over the phone, computer or any other forms of information and communication technologies (ICT). Nursing telepractice is the delivery, management and coordination of care and services provided via ICT.

When utilizing ICT for telepractice, RNs and NPs must ensure they continue to uphold their standards, competencies and code of ethics. The importance of clinical knowledge, nursing judgment, communication and documentation skills is paramount when establishing and maintaining a nurse client relationship through telehealth. More information for nursing telehealth activities can be found in the resource section below.

To provide telehealth to a Saskatchewan resident, you must be registered and hold a practicing license with the CRNS. The Registered Nurses Act, 1988 in Saskatchewan outlines the need to be registered to engage in the practice of registered nursing and to use protected titles. Information about registration can be found here.

Each province/territory and country is governed by differing legislation/regulations/bylaws. It is important to contact the nursing regulator in that jurisdiction before providing telehealth services to their residents.

Questions about registration can be directed to Regulatory Services by email at register@crns.ca or by calling 306.359.4200 or 1.800.667.9945 (toll free within Canada).

For a confidential consultation about a practice issue, please contact a Practice Advisor by email at practiceadvice@crns.ca or call 306.359.4200 or 1.800.667.9945 (toll free within Canada).

Resources:      

Van Houwelingen, C. et al. (2016). Competencies required for nursing telehealth activities: A Delphi-study. Nurse Education Today, 39, 50-52. https://www.sciencedirect.com/science/article/pii/S0260691716000149

Canadian Nurses Protective Society, www.cnps.ca

Canadian Nurses of Ontario (CNO) (2017). Practice Guideline: Telepractice CNO Practice Guideline: Telepractice

Changes to Prescription Review Program Panel of Monitored Drugs

As a partner to the Prescription Review Program (PRP), the College of Registered Nurses of Saskatchewan (CRNS) is sharing the following update with all Nurse Practitioner members in the province.

As outlined in CRNS Bylaw (2019) VI – Categories of Practice, Section 4 The Prescription Review Program, (2) Panel of Monitored Drugs, the Prescription Review Program shall apply to all dosage forms of the drugs listed in the panel of monitored drugs contained in the bylaws of the College of Physicians and Surgeons of Saskatchewan as amended from time to time.

The College of Physicians and Surgeons (CPSS) has provided the following information to their members, which also applies to all NPs. Please be advised of the amendment to The College of Physician and Surgeons of Saskatchewan’s Regulatory Bylaw 18.1(a) Panel of Monitored Drugs.

The highlighted drugs reflect the new additions, effective immediately.

Review the full list of changes from The College of Physician and Surgeons of Saskatchewan here.

We have received a number of calls lately about telehealth and the ability to provide this service. Telehealth connects patients and health care providers who provide health services over the phone, computer or any other form of information and communication technologies (ICT).

Providing telehealth to a Saskatchewan resident

To provide telehealth to a Saskatchewan resident, you must be registered and hold a practicing license with the CRNS. The Registered Nurses Act, 1988 in Saskatchewan outlines the need to be registered to engage in the practice of registered nursing and to use protected titles. Information about registration can be found here.

Questions about registration can be directed to Regulatory Services by email at register@crns.ca or by calling 306.359.4200 or 1.800.667.9945 (toll free within Canada).

Providing telehealth to clients who are residents of another province or territory

Each province/territory and country is governed by differing legislation/regulations/bylaws. We encourage you to contact the nursing regulator in that jurisdiction before providing telehealth services to their residents.

A national discussion is currently underway to examine the delivery of telehealth services across the country. We will provide updates on this issues as further information becomes available.

For a confidential consultation about a practice issue, please contact a Practice Advisor by email at practiceadvice@crns.ca or call 306.359.4200 or 1.800.667.9945 (toll free within Canada).