Nursing Practice Updates

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

Evidence shows that measures such as handwashing, masking and social distancing are effective strategies to prevent the spread of COVID-19. At this time, as COVID vaccines are being administered to the residents of Saskatchewan, the CRNS wants to remind RNs and NPs about expectations related to providing advice on public health protection and prevention measures.

RNs and NPs are leaders in the community. The public’s trust may extend to the views expressed by RNs and NPs on health matters communicated on social media and other forums. As such, statements made by RNs and NPs in public forums have the potential to impact the health and safety of the public.

RNs and NPs have a professional responsibility and are accountable to:

• use evidenced-based information to inform their professional practice;
• support patients and the public to make informed health care decisions, including decisions about public health prevention and protection measures; and,
• role model and follow public health directives that keep patients and the public safe.

The CRNS’s expectations of RNs and NPs regarding public statements, are outlined in the Registered Nurse Practice Standards, Registered Nurse Entry-level Competencies, Nurse Practitioner Practice Standards, Nurse Practitioner Entry-level Competencies and the Code of Ethics for Registered Nurses.

The CRNS’s standards, entry-level competencies and code of ethics do not apply to all aspects of an RN’s or NP’s private life. However, those who choose to make public comments, while identifying themselves as an RN or NP, are accountable to the CRNS and the public it protects.

RNs and NPs are expected to adhere to the standards, entry-level competencies and code of ethics when carrying out their professional responsibilities. They have a professional responsibility to provide evidence-based information and care. Making anti-vaccination, anti-masking and anti-distancing comments may result in an investigation by the CRNS, and possible disciplinary proceedings. 

Additional resources

CRNS

• Code of Ethics for Registered Nurses, 2017
• RN Practice Standards, 2019
• RN Entry-Level Competencies, 2019
• NP Practice Standards CRNS, 2017
• NP Entry-Level Competencies, 2017

Social Media

• Social Media – CRNS
• Social Media – CNPS

Government of Saskatchewan

• COVID-19

Government of Canada

• Coronavirus disease (COVID-19)

As a member of the national steering committee, the CRNS is participating in the Nurse Practitioner Regulation Framework Implementation Plan Project (NPR-FIPP). This project is a multi-year, multi-faceted initiative commissioned by the Canadian Council of Registered Nurse Regulators (CCRNR).

The goal of NPR-FIPP is to implement the recommendations endorsed by CCRNR regarding six basic elements of a model for Nurse Practitioner regulation in Canada. These six elements include entry level education programs, the creation of one national entry-level examination for all NPs across Canada, common standards of practice, continuing competence, one NP registration category based on entry-level competencies and common principles for re-entry to practice. The first-year priority will focus on beginning work on an entry level examination and entry level education programs.

For additional information about the project, visit the CCRNR website.

If you have any questions about the project and/or the CRNS’s role, please contact Donna Cooke, Nursing Advisor, Regulatory Services at dcooke@crns.ca or phone 1-800-667-9945 (ext. 202) or 306-359-4202.

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)

In response to an updated Health Canada advisory warning that patients under 18 years of age should not use non-prescription pain relief products containing codeine, the Prescription Review Program (PRP), Saskatchewan’s prescription monitoring program, has released correspondence to assist practitioners with the management of pediatric pain and provide guidance in regards to the use of codeine products. 

The update by Health Canada also included warnings regarding the use of prescription cough and cold products containing opioids in patients under 18 years of age. Research has suggested that early exposure to opioids may put young patients at risk for opioid-related adverse events throughout their life. 

Given it’s perceived safety, codeine was previously a preferred opioid drug in pediatrics, it has since been recommended that practitioners do not initiate treatment with codeine if the patient hasn’t been prescribed the drug for a chronic condition in the past. 

Correspondence shared by the Prescription Review Program, elaborates on the above topics further, outlines non-opioid and non-pharmacological options in pediatric pain management and highlights important reminders if an opioid prescription is deemed necessary in a pediatric patient. 

Review this document here. 

If you have any questions, please contact Susan Furman-Pelzer, NP Nursing Advisor PRP (prp@crns.ca). 

The CRNS is currently in the process of revising the Self-Employed Practice Guidelines. The Self-Employed Practice Guidelines provide guidance for RNs and NPs who are interested in setting up their own practice. The guideline covers such topics as the legislation and regulatory requirements for self-employed practice, confidentiality, consent, considerations when treating family and friends, information management, policy and procedure development, and liability protection.

The CRNS is seeking feedback on this document from the public, partners, and member. Feedback can be provided by accessing the survey here. The document can be accessed here.

Final approval occurs through the CRNS Executive Director and CRNS Council. The guideline will take effect on the CRNS Council approval date.

Questions or comments are welcome and can be directed to practiceadvice@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.

The current Health Canada section 56 exemption that was set to expire on September 30, 2020 has been extended to September 30, 2021. This exemption provides practitioners with the authority to issue a verbal prescription for controlled substances. There are no changes to the exemption and 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. View the update here.

In recent changes made to the Food and Drug Regulations (FDRs), Nurse Practitioners will be included as a “practitioner” to whom drug samples may be distributed.

On March 13, 2020, Bill C-4 (the Canada–United States–Mexico Agreement Implementation Act) received Royal Assent and came into effect July 1, 2020. The Canada-United States-Mexico Agreement (CUSMA) included regulatory commitments specific to products recognized as being at the interface of cosmetics and drugs. Among other things, the Act amends section 14 of the Food and Drugs Act (i.e., the prohibition on the distribution of drugs as samples).

Corresponding amendments were made to the Food and Drug Regulations (FDRs), including amendments to section C.01.048, to permit the distribution of drugs as samples to a “practitioner”. “Practitioner” is now defined in the FDRs, referring to a person who is entitled under the laws of a province or territory to treat patients with a prescription drug; therefore will include Nurse Practitioners as a “practitioner” to whom drug samples may be distributed. These changes permit distribution of drugs as samples to clients, as a matter falling within the Nurse Practitioner’s scope of practice. Other practitioners with prescribing authority under provincial and territorial law but who could not (prior to these amendments being made) receive samples of prescription drugs and NPDs include chiropodists (podiatrists), optometrists, naturopaths and midwives.

As part of the CUSMA implementation, Health Canada established a guidance document on the distribution of drugs as samples, as well as lists of the specific non-prescription drugs and natural health products that can be distributed as samples directly to consumers. Health Canada also established a list of the non-prescription drugs for which additional (i.e., identity and confirmatory) testing is not required upon importation and may be directly shipped to retailers or wholesalers.

Further to this guidance document, Health Canada wishes to advise interested stakeholders of the steps that are being undertaken to expand the lists of products described above, as follows:

1. Amend List A: List of Certain Natural Health Products for Distribution as Samples to include all currently authorized products in the product categories set out in the CUSMA and meeting the identified criteria, i.e., for topical use, localized and non-systemic effect, and meets the definition of a “cosmetic”.

2. Amend List D: List of Certain Non-prescription Drugs for Distribution as Samples to include all currently authorized products in the product categories set out in the CUSMA and meeting the identified criteria, i.e., for topical use, localized and non-systemic effect, and meets the definition of a “cosmetic”.

3. Amend the List of Non-prescription Drugs for Which the Testing Requirements Set Out in Subsections C.02.019 (1) and (2) of the Food and Drug Regulations Do Not Apply to include all currently authorized products in the product categories set out in the CUSMA and meeting the identified criteria, i.e., for topical use, localized and non-systemic effect, and meets the definition of a “cosmetic”.

If you have any questions, please contact the Natural and Non-prescription Health Products Directorate at: hc.nnhpd.consultation-dpsnso.sc@canada.ca

More information on the amendments here.

The CRNS is currently reviewing the Graduate Nurse Practice Guideline and is seeking feedback on the content. This guideline provides information about topics such as the professional expectations, scope of practice and supervision requirements for Graduate Nurses (GN).

CRNS staff have reviewed and revised the existing document and are now seeking feedback from the public, partners and members as part of the external consultation process. This process is in place to ensure relevant information is clearly presented. Feedback can be provided by accessing this survey by August 7, 2020. All feedback will be reviewed and incorporated as appropriate.

Final approval occurs through the CRNS Executive Director and CRNS Council. The guideline will take effect on the CRNS Council approval date.

Questions or comments are welcome and can be directed to practiceadvice@crns.ca.

Nursing Practice Update: Joint Statement – Supporting Saskatchewan Regulated Health Care Professionals During the COVID-19 Response

The COVID-19 pandemic is difficult and challenging for our health care system. During a surge in COVID-19 cases, you may be required to adapt your usual practice. A joint statement outlining principles and practice expectations for you and other regulated health care professionals has been developed to support clarity during these challenging times. Read the Full Statement

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

The CRNS is closely monitoring the ongoing COVID-19 outbreak to provide support to RNs, RN(AAP)s, NPs, employers and provincial leadership. View the COVID-19 Update page for current updates and information regarding the ongoing pandemic.

Covid-19 Update Page

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.

As of November 5, 2019, the updated Clinical Decision Tools (CDTs) for RNs with Additional Authorized Practice [RN(AAP)s] have been adopted by CRNS Council and will be in effect beginning December 1, 2019. As of this date, the older versions of the CDTs will no longer be in effect.

The evidence and best practice guidelines have been reviewed and incorporated into the updated CDTs with in-text sources included. The Interprofessional Advisory Group (IPAG) reviewed, revised and approved all of the CDTs. During this process, it was determined that some Pediatric and Adult CDTs could be merged to streamline the processes. Additionally, charts and tables have been added to support effective and clear messaging about pharmacology options and other information within the CDTs. Language has been updated to reflect non-binary genders, for example people of reproductive age rather than women of childbearing age, and reproductive health rather than women’s health.

While the literature review is complete and all CDTs are updated for evidence-informed best practice for RN(AAP)s to diagnose, treat and prescribe for limited common medical disorders, there are no significant practice changes and no new CDTs.

It is important RN(AAP)s review all CDTs to ensure they are informed about the latest evidence for their practice.

CRNS Practice Advisors may be contacted for answers to your practice questions by email at practiceadvice@crns.ca or by phone 306.359.4200 or 1.800.667.9945 (toll free within Canada).

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).

On March 27, 2019, CRNS Council passed the two policies that allow NPs, who regularly see people with Opioid Use Disorder (OUD) or who require methadone for pain, to apply to the CRNS to receive approval to prescribe medications such as suboxone and methadone. These regulatory processes are in follow up to the Bylaw passed by CRNS membership at the 2018 CRNS Annual Meeting. Based on this Bylaw, the CRNS has worked with provincial and national partners, including the Saskatchewan Health Authority, the Ministry of Health, the College of Physicians and Surgeons of Saskatchewan, Interdisciplinary Advisory Committees, and NP Advisory Committee, to develop the education and clinical practicum requirements, and regulatory processes.

The CRNS has developed regulatory processes to minimize harm to the public and develop expectations for safe prescribing. In accordance with the CRNS mandate to set standards for competence and govern prescribing, NPs must meet all requirements prior to receiving approval to prescribe drug therapeutics for OUD and methadone for pain. The NP prescribing of these additional medications will be monitored through the existing Prescription Review Program.

Advancing the NP Scope of Practice by enabling NPs to prescribe drug therapeutics for OUD will increase the number of approved prescribers in Saskatchewan; thereby providing increased access for clients.

Eligible NPs can begin the application process as of April 2, 2019.

With the legalization of recreational cannabis on October 17, 2018, new Cannabis Regulations have replaced the Access to Cannabis for Medical Purposes Regulations (ACMPR). Under the new regulations, a nurse practitioner is defined as an authorized health care provider and is not restricted, under the laws of the province in which they practise, from authorizing the use of cannabis.  The College of Registered Nurses of Saskatchewan (CRNS) has determined that it is within the NPs scope of practice whom have the appropriate knowledge, skills and competencies to safely authorize the use of medical cannabis for Saskatchewan clients.

It is important NPs educate clients on the risks, side effects, safe transportation and storage of medical cannabis. NPs are required to adhere to employer policy for authorizing the use of medical cannabis. Clients authorized by their health care provider are still able to access cannabis for medical purposes by:

• buying directly from a federally-licensed seller,
• registering with Health Canada to produce a limited amount of cannabis for their own medical purposes, and
• designating someone to produce it for them.

Additional resources for NPs:

• Accessing cannabis for medical purposes
• Cannabis for medical purposes under the Cannabis Act: information and improvements
• Medical Document Authorizing the use of Cannabis for Medical Purposes under the Access to Cannabis for Medical Purposes Regulations
• Information for Health Care Practitioners – Medical Use of Cannabis
• Information for Health Care Professionals: Cannabis and the cannabinoids
• Cannabis Legalization Resources
• Controlled Drugs and Substances Act
• New Class of Practitioner Regulations
• Narcotic Control Regulations
• The Drug Schedules Regulations

CRNS Nursing Advisors are available to discuss practice questions about cannabis. To contact the CRNS for practice advice, please call: 1-800-667-9945 or 306-359-4200 (ask to speak to a practice advisor), or you can email at practiceadvice@crns.ca

Mifegymiso is an antihormonal medication consisting of two medications (mifepristone and misoprostol) that work together to block the effects of progesterone for termination of early pregnancy.

Health Canada recently broadened the interpretation of Mifegymiso prescriber to include prescribing health professional, resulting in Nurse Practitioners having the legal authority to prescribe Mifegymiso within Canada. The College of Registered Nurses of Saskatchewan (CRNS) has determined that it is within the NP’s scope of practice whom have the appropriate knowledge, skills and competencies to prescribe Mifegymiso to Saskatchewan patients.

Additional resources for NPs:

• Review the Product Monograph, Patient Medical Information, the Patient Consent Form and the Patient Information card that can be found on the Celopharma website: celopharma.com
• Consider completing the accredited training program through the Society of Obstetricians and Gynecologists of Canada (SOGC); or the online education program through the Celopharma website specific to Mifegymiso inclusive of the Risk Communication

An interdisciplinary advisory group is working with CRNS staff to develop council policy that fully defines the educational, practicum, monitoring and audit requirements. The projected timeline to have policies approved by CRNS Council is by Dec. 31, 2018. CRNS will provide updates as the work progresses.