Nursing Practice Updates

The Saskatchewan Health Authority began the launch of the provincial Iron Deficiency Anemia (IDA) Management program on June 3, 2024. Implementation of the program involves a mandatory outpatient IV iron order set that can be accessed here. The order set is scheduled to be gradually rolled out across the province in the coming months. A memo containing a more detailed site-specific timeline can be found here. The program will affect ALL OUTPATIENT IV iron prescribing once implemented in your community.

IDA Management Program Pharmacists are available to answer your questions. Please find their info below. Live virtual education sessions will be offered for those interested. Dates to follow.

Ben Kinsley (Regina/South)                          Brent Vanin (Saskatoon/North)

Ph: 306 766 2896                                           Ph: 306 655 6077

Ben.kinsley@saskhealthauthority.ca         brent.vanin@saskhealthauthority.ca

RNs and NPs are professionally accountable for how they convey their self-employed practice/business to the public through advertising. The purpose of advertising is to provide information so the public can make an informed decision when selecting registered nursing services from a self-employed registrant. Registrants may engage in advertising their nursing services for the purpose of promoting, maintaining or restoring health; and, preventing illness and alleviating suffering.

Registrants who advertise nursing services shall:

• comply with federal, provincial and CRNS legislation; 
• present information in a manner consistent with the current practice standards, entry-level competencies and the code of ethics;
• advertise services only within the legislated scope of the registrant; 
• state full name and protected title in the advertisement;
  • CRNS designation may only be used once you obtain Recognition of Practice (ROP) approval, or if the nursing services are designated nursing activities as interpreted by the Act; 
• provide an accurate written description of the services provided, including risks and benefits of the service; 
• address any actual, potential or perceived conflict of interest;
• obtain informed consent and always maintain client privacy and confidentiality;
• use reasonable and appropriate illustrations, images, representations or claims; 
• keep a copy of all advertisements for a reasonable time (suggested 5-year retention, or as suggested per legal counsel) for your record keeping;
• only provide and advertise health services or products that are authorized for sale in Canada by Health Canada;
• avoid comparative statements that claim or imply superiority over others or include promotional/sale advertising;
• ethically manage the potential risks associated with endorsements, refraining from endorsing products, product line or health care services that are not related to the care or services provided;
• do not mislead the public with exaggerated claims of the effectiveness of the service being provided; and,
• ensure advertisements are presented in a manner that maintains the public’s trust and are accurate, factual, evidence-based, verifiable, ethical and professional. 

CRNS Nursing Advisors are available to answer your questions. They can be contacted by phone at 1.800.667.9945 or 306.359.4227 or by email at practiceadvice@crns.ca. 

Resources

Aesthetics Nursing Resource

Self Employed Practice Guideline

Recognition of Practice (ROP) Information Page

The Canadian Code of Advertising Standards

The Registered Nurses Act, 1988

The Saskatchewan Ministry of Health has provided updated information regarding the prescribing and dispensing of COVID-19 therapeutics such as Paxlovid. The May 30, 2024 letter can be accessed here.

CRNS Nursing Advisors are available to answer your questions. They can be contacted by phone at 1.800.667.9945 or 306.359.4227 or by email at practiceadvice@crns.ca. 

There have been several questions and requests for clarification in follow up to the Long-Term Care – Authorized Prescriptions joint statement that was sent out by CPSS, CRNS, CLPNS and SCPP. Legislation requirements were included in the original joint statement. This second joint statement has been issued to provide further clarity regarding the use of verbal/telephone orders to dispense a prescription in a Long-Term Care (LTC) setting.

Pharmacists

• Must receive orders to dispense a prescription directly from a physician, NP, RN (AAP), dentist and other authorized prescribers.
• May accept a verbal/phone or faxed original prescription written and signed by an authorized prescriber.
• May receive a faxed transcribed order from a nurse as a means of communication so the pharmacist can expect an order from the authorized prescriber and alerts the pharmacist to follow up with the prescriber if the prescription is not received.

Physicians

• May provide nurses with a telephone/verbal order to facilitate timely patient care.
• Must provide pharmacists with an order directly to authorize the pharmacist to dispense a prescription.

Nurses

• May take telephone/verbal orders from an authorized prescriber and may fax the transcribed order to the pharmacist for communication purposes.
• Cannot act as a third party in the direct communication required between the authorized prescriber and the pharmacist when there is an order to dispense a prescription.

CRNS Nursing Advisors are available to answer your questions. They can be contacted by phone at 1.800.667.9945 or 306.359.4227 or by email at practiceadvice@crns.ca.

Nurse Practitioners (NPs) provide excellent care in primary health care settings and a variety of specialized clinical contexts throughout Saskatchewan. CRNS has become aware of a clinical practice issue that is having negative impacts on patient outcomes and leading to potential patient privacy breaches due to misrouted medical imaging reports. Several of the identified causes are listed here:

• Many NPs have more than one clinical site where they work. 
• NPs may concurrently work within and outside of the SHA and order or request medical imaging studies for clients.
• The CRNS database that verifies registration status of NPs does not contain clinic phone numbers, fax numbers or addresses. Therefore, it is not a resource that enables technologists to appropriately forward medical imaging reports.
• The Radiology Information System (RIS) can only support one fax number per provider. Providers working at multiple sites must make arrangements with clinic staff at that site (the one with the distribution fax), to create a workflow so that the NP’s can receive their patient’s reports and booking notifications at any/all sites that they are providing patient care.
• There are many different requisitions/ forms that are utilized when NPs order or request medical imaging studies in the various settings where they work.
• Paper requisitions are not handled consistently by all SHA facilities. The SHA Medical Imaging Department cannot guarantee that the information on the requisition is translated through from request to finalization. The SHA Medical Imaging Department requires one fax for ALL reports and booking confirmations.

These factors can create barriers that lead to delays in care or privacy issues. CRNS is raising awareness of this issue and is recommending the following:

• NPs ensure that clinic specific information is included on the medical imaging requisitions to enable more timely and accurate delivery of results to the appropriate location. 
• NPs currently working only in one location may wish to ensure that their contact information is up to date.
• NPs should update the RIS team each time they change their work location to ensure the best possible outcomes. 
• NPs working in multiple sites should make arrangements with clinical staff to create a workflow to ensure that they are receiving all of their patient’s results in a timely manner.

The Saskatchewan Biosimilars Initiative was created to improve the uptake of biosimilar drugs. The Biosimilars Initiative means that patients are covered for a biosimilar version of their biologic medication where one is available. 

Visit the Biosimilars Initiative website for the most current and up-to-date news regarding this initiative.

The CRNS is pleased to announce the release of the updated Medical Assistance in Dying Guideline (2024). The Medical Assistance in Dying Guideline was approved by CRNS Council on February 23, 2024.

The guideline was updated to reflect best practices and standards as outlined in the nationally developed Model Practice Standard for Medical Assistance in Dying (MAID) and the Saskatchewan Health Authority (SHA) MAID program; Nurse Practitioner (NP) Entry-Level Competencies (ELC) were updated to the 2023 version; and the date in which people whose sole underlying medical condition is mental illness and wish to seek MAID was updated to reflect federal legislation and is March 17, 2027.

Reviewing this document will assist you in knowing the expectations of RN and NP practice in providing care to people seeking MAID. CRNS Practice Advisors are available to answer your questions. They can be contacted by phone at 1.800.667.9945 or 306.259.4227 or by email at practiceadvice@crns.ca.

The SCPP, the CRNS, the CLPNS, and the CPSS have issued a joint statement regarding verbal orders generated from Long Term Care (LTC) Facilities. A pharmacist may only accept a verbal or faxed original order written and signed by an authorized prescriber e.g. physician, NP, dentist. A pharmacist may not accept a verbal or faxed written order (transcribed) from an RN. The full statement can be accessed here.

CRNS Nursing Advisors are available to answer your questions. They can be contacted by phone at 1.800.667.9945 or 306.359.4227 or by email at practiceadvice@crns.ca. 

Cervical cancer screening in Saskatchewan recently changed when the revised cervical cancer screening clinical practice guidelines were updated in November 2023. Key changes to the new guidelines include:

• Screening will start at age 25 or three years after becoming sexually active, whichever is later;
• Routine screening will now be every three years until the age of 69; and,
• The addition of Human Papillomavirus (HPV) reflex testing. 

These new evidence-based changes ensure people continue to benefit from screening while avoiding unnecessary tests and follow-up treatment. 

Click here to find information about the guidelines, including the new guidelines document. (link to: http://saskcancer.ca/health-professionals-article/cancer-screening-guidelines-and-resources/cervical-cancer-screening)

The SCA has collaborated with the Department of Obstetrics and Gynecology and the Division of Continuing Medical Education to create a free accredited course on the guidelines. The course will be available until July 2024. It can be found here. (link to: https://cmelearning.usask.ca/learn-here/cme-online-courses/cervical_cancer_guidelines_online-course.php)

If any questions arise about the guidelines, please feel free to reach out to the Screening Program for Cervical Cancer at ED.Coordinator@saskcancer.ca.

The evolution of independent for-profit (stand-alone) clinics providing intravenous (IV) hydration therapy has prompted many calls to the CRNS. After completing environmental scanning and a review of best practices, the CRNS has determined that it is within the scope of practice of Registered Nurses (RN) to administer IV hydration therapy and medications, vitamins, and/or electrolytes (additives) while working in stand-alone clinics so long as the nursing process is implemented and appropriate policies and supports are in place to support safe, competent, and ethical care of this client population.  

RNs and Nurse Practitioners (NP) are accountable to practice within their legislated scope of practice and personal competence and to adhere to their Practice Standards and Code of Ethics as they would in any other practice setting.  Registrants must complete the Recognition of Practice process to use the title RN and/or NP and to count the practice hours they have worked in an IV hydration clinic towards licensure.

With the growing popularity of IV hydration therapy and individuals “self-selecting” treatments – for example, to relieve the effects of a hangover, there is an increasing trend of complaints related to unsafe practices and untoward events reported in Canada and the United States.  It is essential for RNs and NPs engaged in this practice to understand that IV hydration is a medical treatment and, therefore, there must be a medical condition for the client to obtain the treatment. As with all treatments and interventions, the risks of accepting treatments should be disclosed to the client and informed consent obtained.   

To provide safe, competent nursing care and to meet the requirements for Recognition of Practice, the following must be in place when performing IV hydration therapy treatments:

1. Appropriate policies, procedures, and resources.
2. A health history and physical examination must be performed and documented by the prescribing NP or physician to ascertain if underlying co-morbidities, such as congestive heart failure or kidney disease, might be a contraindication to the client receiving treatment.
3. Provision for diagnostic testing, as indicated for co-morbidities, should be completed as part of the client assessment. Diagnostic testing should be considered to establish a baseline for ongoing treatment.
4. The infusion must be prescribed to treat a diagnosed medical condition; clients must not “self-select” treatments. 
5. There must be an order from an NP or physician for the RN to initiate the IV and/or administer the IV solution and additives.
6. There must be appropriate documentation, including the client assessment, client consent, treatment ordered and administered, and client response to that treatment.
7. The supplies, including IV lines, solution, and additives, must be procured from a reputable source and stored and handled in alignment with current infection prevention and control (IPAC) best practices and principles. 
8. There must be an ability to manage untoward events, including having the necessary emergency equipment on site.

For more information or to inquire about recognition of practice, please contact a nursing practice advisor practiceadvice@crns.ca.

In the 2022 updated regulatory bylaws that were approved and published in the September 9, 2022, Saskatchewan Gazette and came into effect on November 1, 2022, it included an update to Bylaw VI Categories of Practice, Section 3 Nurse Practitioner Category, which enables NPs to order or request medical imaging. This involves the application or detection of forms of energy for diagnostic and screening purposes and to receive and interpret reports, or to perform ultrasound imaging for the sole purpose of point-of-care diagnostic assistance when it is in the best interest of the client, in accordance with their practice standards and code of ethics, when they have the competence and judgment to safely do so, when it is in alignment with best practice evidence and when agency policy permits.

In our work to facilitate RNs and NPs practicing to their full scope, we’ve worked with the Saskatchewan Health Authority (SHA) to minimize disruptions and fully support NPs with equal opportunity to order diagnostic imaging exams SHA provides to General Practitioners (GP).

This allows access to almost all diagnostic testing services.

For MRI and PET/CT exams, NPs and GPs may require additional documentation of approval following a discussion with a radiologist, or a recommendation for such an exam in a previous medical imaging diagnostic report.

If an NP is experiencing challenges ordering diagnostic imaging, please get in touch with Jordan Vercaigne, Manager of Provincial Diagnostic Imaging Standards and Operations, at 306.491.8220.

Effective March 31, 2022, tramadol will be removed from the Prescription Drug List (PDL) and listed in Schedule 1 of the Controlled Drugs and Substances Act (CDSA). Tramadol will also be listed as item 19 in the Schedule of the Narcotic Control Regulations (NCR). This means that tramadol will be subject to all the regulatory requirements set out in the CDSA and NCR. The rational to change the listing is to reduce risks to human health, and to facilitate the detection and prevention of diversion of tramadol.

For a full explanation, including impact to practice, please visit:

https://gazette.gc.ca/rp-pr/p2/2021/2021-03-31/html/sor-dors43-eng.html

If you have any question about your NP practice, please contact practicadvice@crns.ca.  If you have any questions about prescribing controlled drugs and substances or the CRNS

Prescription Review Program, please contact prp@crns.ca

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