RNAO Submission On RN Prescribing Competencies
RNAO Submission on RNPrescribing CompetenciesSubmission to the College of Nurses ofOntarioNovember 9, 2018158 Pearl Street, Toronto, ON M5H1L3.Ph. 416 599 1925.Toll-free 1 800 268 7199.Fax 416 599 1926.RNAO.ca
Summary of RNAO RecommendationsRecommendation 1. Ensure the description of changes to the Nursing Act, 1991 reflects the wording in thelegislation.Recommendation 2. Align and ensure consistency of RN prescribing competencies with existing College ofNurses of Ontario competency frameworks.Recommendation 3. Incorporate RNAO’s suggested re-ordering and edits to RN prescribing competencies.Recommendation 4. Clarify the intent of the interpretation section of the draft RN prescribing competencies,and whether the content is part of the competencies.RNAO Submission to CNO on RN Prescribing Competencies2
IntroductionThe Registered Nurses’ Association of Ontario (RNAO) is the professional association representing registerednurses (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 RNprescribing competencies. RNAO has long advocated for independent RN prescribing.1 2 3 RNs are autonomoushealth professionals who practise independently and collaboratively within interprofessional teams. With morethan 100,000 RNs registered to practise with the CNO,4 RN prescribing has huge potential to increase access tocare across the province.RNAO believes the independent RN prescribing model is the right framework to improve access to carebecause it recognizes the broad depth of RN expertise and ensures RNs are fully accountable for their practice.In Ontario, RNs enter practice with knowledge of pharmacology, immunology, microbiology, anatomy,physiology, pathophysiology, epidemiology, genetics, and nutrition. RNs are proficient in interpreting andapplying evidence in their practice, and will approach independent prescribing in the same manner.Independent prescribing will allow RNs to prescribe medications under their own authority within a regulatedscope of practice and within their clinical competency area.RNAO supports a phased-in approach that will lead to the implementation of independent RN prescribing.RNAO Feedback on the Introductory Sections of RN Prescribing CompetenciesRNAO welcomes the CNO’s draft RN prescribing competencies as a benchmark for the knowledge, skill, andjudgment of RNs who prescribe. RNAO is pleased with how the CNO laid out the assumptions underlying RNprescribing competencies.In the background section, RNAO recommends ensuring the description of the changes to the Nursing Act, 1991more directly aligns with the wording in the legislation. Background, paragraph 2. We suggest replacing “ the Nursing Act to permit registered nurses (RNs)to perform two new controlled acts: 1) prescribing certain medications ” with “ the Nursing Act topermit registered nurses (RNs) to perform two new controlled acts: 1) prescribing drugs designated inthe regulations ” [emphasis added to clearly show RNAO’s recommended change].5Recommendation 1. Ensure the description of changes to the Nursing Act, 1991 reflects the wording in thelegislation.RNAO Submission to CNO on RN Prescribing Competencies3
RNAO Feedback on the Organization of RN Prescribing CompetenciesAs the RN prescribing competencies build and expand upon the existing competencies required of RNs, RNAOrecommends organizing the RN prescribing competencies using consistent headings and consistent languagewhere possible across all competency documents.To this end, RNAO recommends that, where appropriate, prescribing competencies build on the framework forEntry-to-Practice Competencies for RNs by aligning with the headings: Professional responsibility &accountability, Knowledge-based practice, Ethical practice, and Self-regulation.6 This is appropriate because theRN prescribing competencies expand on the RN entry-to-practice competencies.Furthermore, prescribing competencies can align with the Entry-to-Practice Competencies for NPs through theuse of the heading: Client care.7 This heading is not found in the Entry-to-Practice Competencies for RNs,however, fits well with RN prescribing competencies by outlining competencies related to the full continuum ofclient care specific to prescribing.Recommendation 2. Align and ensure consistency of RN prescribing competencies with existing College ofNurses of Ontario competency frameworks.RNAO Feedback on the Content of RN Prescribing CompetenciesRNAO’s recommendations on the content of RN prescribing competencies are presented in the first column ofthe below table, organized according to RNAO’s proposed headings: Professional responsibilities and accountabilities. RNAO supports competencies that outline theprofessional responsibilities and accountabilities of RNs who prescribe. Knowledge-based practice. RNAO recommends the inclusion of competencies that outline theknowledge required for RNs who prescribe, and for these competencies to be organized in this existingCNO competency category.8 This section incorporates competencies previously under the draft RNprescribing competencies heading “Pharmacotherapy and Other Therapeutic Interventions in ClientCare”. Ethical practice. RNAO supports competencies related to the ethical practice of RNs who prescribe beorganized within this existing CNO competency category.9 Self-regulation. RNAO supports competencies related to the self-regulation of RNs who prescribe beorganized within this existing CNO competency category.10 Client care. RNAO recommends the inclusion of competencies that outline the full continuum of carefor RNs who prescribe to be organized within this existing CNO competency category.11 This sectionincorporates the competencies previously under the draft RN prescribing competencies heading“Assessment & Diagnosis” and “Pharmacotherapy and Other Therapeutic Interventions in Client Care”.RNAO Submission to CNO on RN Prescribing Competencies4
The second column of the table contains the original CNO draft competency, with the original numbering forclarity and comparison. The third column of the table contains explanation and rationale for the recommendedchanges. RNAO recommended additions are bolded, and RNAO recommended deletions have a strike-through.Professional responsibilities and accountabilitiesRNAO recommended competencywording and orderCNO draft competencyRationale for RNAOrecommendations1. Demonstrates understanding ofthe legislated scope of practiceof the RN who prescribes.1a) Demonstrates understanding ofthe legislated scope of practice ofthe RN who prescribes, includingrelevant laws, College standardsand guidelines.Remove examples of the legislatedscope of practice, to increaseconsistency with CNO’s Entry-toPractice Competencies for RNs.12Details of scope of practice can beincorporated in the interpretationsection (e.g., laws, regulations, andCollege standards and guidelines).2. Demonstrates understanding ofprofessional accountability ofthe RN who prescribes.1b) Demonstrates understanding ofprofessional accountabilityassociated with prescribing andcommunicating a diagnosis, andawareness that theseaccountabilities cannot bedelegated to another individual.Remove extra wording andunnecessary details to be moreclear and concise. Details andexamples of professionalaccountability can be incorporatedin the interpretation section (e.g.,limitations to delegation).3. Demonstrates understanding ofthe roles and responsibilities ofthe RN who prescribes withinthe health care team.1d) Demonstrates understanding ofthe roles and responsibilities of theRN who prescribes within thehealth care team.No changes.4. Clearly articulates the role ofthe RN who prescribes wheninteracting with the client.1e) Clearly articulates the role ofthe RN who prescribes wheninteracting with the client.No changes.5. Recognizes when the client'shealth needs - at any pointduring the continuum of care- are beyond the scope,knowledge, skills, andcompetencies of the RN whoprescribes. Collaborates,1f) Recognizes when the client'shealth needs - at any point duringassessment, diagnosis or treatment- are beyond the scope, skills,knowledge and competencies of theRN who prescribes, and consultswith, or refers the client to, anotherSeparate the competency into twosentences. Wording from CNO’sEntry-to-Practice Competencies forNPs was adapted to inform thesecond sentence.13RNAO Submission to CNO on RN Prescribing Competencies5
consults, or refers to anotherhealth-care provider whennecessary for safe, competent,and comprehensive clientcare.health care provider.1g) Manages expectations andpressures to prescribe frommultiple sources.Eliminate this competency as it isunnecessary. Managingexpectations and pressures is partof professional accountability andethical decision making, which areexisting competencies. It is not aseparate competency for otherprescribers (i.e., NPs).6. Reports adverse events toclients and/or appropriateauthorities, in keeping withrelevant legislation andorganizational policies.1h) Demonstrates understand ofHealth Canada reportingrequirements for adverse drugreactions.Use the wording from CNO’sEntry-to-Practice Competencies forNPs for consistency.14 Details ofreporting requirements can beincorporated in the interpretationsection.7. Understands and contributesto organizational policies andprocesses for safe prescribingpractices.1j) Contributes in the development,implementation, and evaluation oforganizational policies andprocesses approaches for safeprescribing practices.Remove unnecessary extra wordingto be more clear and concise.8. Implements person-centredcare, engaging in shareddecision-making in all aspectsof client care.1k) Considers the client'sperspective in all aspects of clinicaldecision-making, includingassessment, diagnosis, andprescribing decisions.Edit language to reflect personcentred care and shared decisionmaking, as supported by evidenceoutlined in the Person- and FamilyCentred Care BPG.15 The Personand Family-Centred Care BPGrecognizes different terms (e.g.,client, resident, patient) that may beused in different settings. RNAOrecommends moving in thedirection of person-centred care.RNAO Submission to CNO on RN Prescribing Competencies6
Knowledge-based practiceRNAO recommended competencywording and orderCNO draft competencyRationale for RNAOrecommendations1. Demonstrates understanding ofprinciples of safe prescribing byengaging in evidence-informedand best practice in prescribing.3.[Sub-heading]Demonstrates an understanding ofthe principles of safe prescribing byengaging in evidence-informed andbest practice in prescribing.Incorporate the current sub-heading(in the draft RN prescribingcompetencies document, it appearsin a shaded grey box) as acompetency. Add an interpretationsection for this competency, tofurther detail and provide examplesof principles of safe prescribing.2. Applies clinical andpharmacological knowledgeand evidence informed practicein prescribing.3b) Applies knowledge ofpharmacology and evidenceinformed practice in prescribingmedications.Edit the language to broadlycapture knowledge required of RNswho prescribe. Additional detailsand examples can be incorporatedin the interpretation section (e.g.,drug interactions).3c) Demonstrates understanding ofdrug interactions.Eliminate this competency as it isunnecessary. Understanding druginteractions is part of thepharmacological knowledge,outlined in the previouscompetency. It is not a separatecompetency for other prescribers(i.e., NPs).3d) Demonstrates understanding ofthe potential safety risks when theRN dispenses or administers amedication that s/he has prescribed,and develops strategies to mitigatesuch risks.Eliminate this competency as it isunnecessary. It is not a separatecompetency for other prescribers(i.e., NPs).Ethical practiceRNAO recommended competencywording and orderCNO draft competencyRNAO Submission to CNO on RN Prescribing CompetenciesRationale for RNAOrecommendations7
1. Demonstrates ethical decisionmaking when prescribingmedication.1c) Demonstrates ethical decisionmaking when prescribingmedication.No changes to wording. Moved thecompetency to align with theorganization of Entry-to-PracticeCompetencies for RNs.16Self-regulationRNAO recommended competencywording and order1. Maintains professionalknowledge and competence inrelation to prescribing byengaging in self-reflection todetermine continuingcompetence needs.CNO draft competency1l) Maintains professionalknowledge and competence inrelation to prescribing by engagingin self-reflection to determinecontinuing competence needs.Rationale for RNAOrecommendationsNo changes to wording. Moved thecompetency to align with theorganization of Entry-to-PracticeCompetencies for RNs.17Client careRNAO recommended competencywording and order1. Reviews information relevantto the client encounter,including information fromother health care providers andlaboratory and diagnosticresults.CNO draft competency2a) Reviews information relevantto the client encounter includinginformation from other health careproviders.Rationale for RNAOrecommendationsIf including language in thecompetency to capture examples ofinformation to review, additionaland highly relevant sources of datashould also be included (e.g.,laboratory and diagnostic results).The interpretation section needs tobe edited to reflect that thiscompetency is regardingestablishing a reason for the clientencounter. The current wordingconfuses the purpose (i.e.,establishing a reason for theencounter) with the separatecompetency of completing a clienthealth history.RNAO Submission to CNO on RN Prescribing Competencies8
2. Conducts relevant healthhistory of the client, includingsymptoms, history ofpresenting issue, past healthhistory, family history,allergies, co-existingconditions, medicationhistory, treatments, andcomplimentary therapies.2b) Collects information on clientstatus and health needs.3. Performs a relevant clinicalexamination, incorporatinginformation from otherhealth care providers,laboratory and diagnosticresults, client history,assessment findings, andspecific client characteristics.2c) Performs a relevant physicalexamination based on assessmentfindings and specific clientcharacteristics.4. Analyzes, interprets, andsynthesizes multiple sourcesof data, including laboratoryand diagnostic results, healthhistory, and clinicalassessment.2d) Uses critical inquiry andclinical reasoning in decisionmaking to synthesize and integratehealth information and to ascertainthat sufficient information has beenobtained about the client's coexisting conditions, currenttreatments and health history, toidentify possible risks andcontraindications.3a) Completes a review of the bestpossible medication history beforeprescribing.Edit the language of thiscompetency to more clearly outlineit refers to completing a healthhistory. A medication history ispart of a complete health history,and thus needs to be incorporated.Wording from CNO’s Entry-toPractice Competencies for NPs wasadapted to inform thiscompetency.18Replace the word "physical" with“clinical” as the former is notinclusive of mental health.If including language in thecompetency to outline what theclient assessment is based on,additional types of highly relevantinformation should also beincluded. Wording from CNO’sEntry-to-Practice Competencies forNPs was adapted to inform thiscompetency.19The current wording is confusing.Reference to ‘risks andcontraindications’ is unnecessary,as this is captured in thecompetencies under knowledgebased practice. Reference to‘ascertaining sufficient informationis obtained’ is unnecessary, as thisis captured in the belowcompetency.Edit the competency to broadlycapture the need to analyze,interpret, and synthesize multiplesources of data.RNAO Submission to CNO on RN Prescribing Competencies9
5. Recognizes when informationabout the client is unclear,incomplete or more informationis required to make safeprescribing decisions, and takesappropriate steps to obtain therelevant information.2e) Recognizes when moreinformation about the client areunclear, incomplete or moreinformation is required to makesafe prescribing decisions, andtaking appropriate steps to obtainthe relevant information.Minor editing is suggested toincrease clarity of this competency.New competency is stronglyrecommended.6. Determines or reviewsdiagnoses within the legalscope of practice, based onclinical reasoning andrelevant information.It is necessary to formulate adiagnosis prior to communicatingwhat that diagnosis is to a client.Wording from CNO’s Entry-toPractice Competencies for NPs wasadapted to inform thiscompetency.207. Identifies and selectsmanagement options withinthe legal scope of practicebased on diagnoses andevidence-informed practice,including no treatment, nonpharmacological, andpharmacological options.2f) Uses critical thinking in clinicaldecision-making by processing andsynthesizing health information toidentify medication option(s)within the legal scope of practice.Broaden the competency to includeall management options (e.g., notlimited to medication) that need tobe considered in formulating a planof care for the client. Wording fromCNO’s Entry-to-PracticeCompetencies for NPs was adaptedto inform this competency.218. Completes accurateprescription(s) in accordancewith legal requirements.3e) Completes accurateprescription(s) in accordance withlegal requirements.No changes to wording. Moved thecompetency as it is part of thecontinuum of care.9. Demonstrates effectivecommunication of assessmentfindings, diagnoses, andmanagement plan to theclient.Demonstrates effectivecommunication to inform client ofdiagnosis through:2g) Discussing assessment findingswith the client.2h) Communicating diagnoses toclients when the RN is prescribingthe medication to treat thediagnosis.Incorporating all aspects of care tobe communicated to the client inone competency. The interpretationsection can continue to include thedevelopment and use ofcommunications skills (e.g.,developmentally and culturallyappropriate communicationtechniques and tools).RNAO Submission to CNO on RN Prescribing Competencies10
New competency is recommendedto be added.10. Demonstrates effectivecommunication of relevantclient care to the health-careteam.As part of working ininterprofessional teams, it isnecessary to communicate clientcare to the health-care team. Thuswe recommend including anadditional competency addressingthis area of practice. CNO’s Entryto-Practice Competencies for RNsdoes not currently capture thisaspect of practice, which is inaddition to collaboration,consultation, and referral.11. Provides education to the clientabout medications, whichincludes: Rationale for the prescribedmedication; The expected action of themedication; The adverse reactions, sideeffects, contraindications,precautions, and potentialinteractions; The administration instructions(e.g; route, frequency,duration); The importance of medicationcompliance; Storage instructions; Strategies to reduce risk ofharms involving medicationmisuse; Follow up plan whereappropriate.Provides education to client aboutmedication, which include:3g) Rationale for the medicationselected.3h) The expected action of thedrug.3i) The side-effects,contraindications, precautions, andpotential interactions.3j) The administration instructionsand important of compliance withprescribed frequency, duration oftherapy and how to store the drug.3g) Strategies to reduce risk ofharm involving medication misuse.3l) Follow up plan whereappropriate.Incorporate all aspects ofmedication education beingprovided to the client in onecompetency. The in
scope of practice, to increase consistency with CNO’s Entry-to-Practice Competencies for RNs.12 Details of scope of practice can be incorporated in the interpretation section (e.g., laws, regulations, and College standards and guidelines). 2. Demonstrates understanding of professional accountability of the RN who prescribes.
Report of Use of the Prescribing Safety Assessment in MPharm Students and Preregistration Pharmacists 1. Background The Prescribing Safety Assessment1 was piloted in 2011/12 as a means of formatively assessing the prescribing abilities of final year medical students in response to concerns about prescribing competences in junior doctors.
Do not withdraw Toujeo from the SoloStar and Max SoloStar single-patient-use prefilled pens with a syringe. References: 1. Toujeo Prescribing Information. 2. Basaglar Prescribing Information. 3. Lantus Prescribing Information. 4. Levemir Prescribing Information. 5. Tresiba Prescribing Information. 6. Toujeo Max SoloStar Instructions for Use.
Yoga for Healing: Why Western Doctors Are Now Prescribing Yoga Therapy 2/13/16, 2:26 PM prescribing-yoga-therapy/) PRESCRIBING-YOGA-THERAPY/) More Western Doctors Are Now Prescribing Yoga
CTD2 Dashboard Submission Builder Tutorial 5 Figure 4: Provide the requested information for the submitter and submission. Guidelines to fill in the fields under the Submission Description Submission Name: A Submission is a Dashboard entry that represents a dataset associated with positive experimental results, a set of data-related figures, or a story.
Prescribing Safety Assessment Assessment Blueprint – August 2018 The Prescribing Safety Assessment has been developed by MSC Assessment and the British Pharmacological Society as a summative assessment of knowledge, judgement and skills related to prescribing medicines in the NHS. It is intended primarily for medical students at or
The Prescribing Safety Assessment 1 was piloted in 2011/12 as a means of formatively assessing the prescribing abilities of final year medical students in response to concerns about prescribing competences in junior doctors. This was extended to all medical schools in 2014 and in 2016
will go into effect on July 1, 2018. Select Florida Law on Controlled Substance Prescribing Prior to HB 21 There are numerous state and federal statutes and regulations that govern the prescribing of controlled substances. HB 21 amended several of the state statutes on controlled substance prescribing. These statutes are briefly discussed below.
10 RNAO Nurse Educator Mental Health and Addiction Resource It is recommended to review this resource by examining the table of contents and bookmarking areas for further review or use at critical points in education and practice activities.
