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CONSULTATION SERVICES

The healthcare system is complex and despite your strong nursing skills and competent training, life sometimes throws you a practice curveball and you need help. One of our most personal and individualized resources we have for you is our confidential consultation services.

Available daily, our experienced Practice Consultants are available to help you explore professional practice questions or issues that may need an objective nursing viewpoint. From there, the Practice Consultants will help you clarify any practice questions and will guide you to nursing materials or resources you may need. Some topic examples include:

  • Documentation and medication administration standards
  • Duty to provide care/client abandonment
  • Resolving professional practice issues
  • Determining scope of practice / RN versus LPN scope of practice (clarification, accountability)
  • Concerns about RN competence

Although the majority of our consultations come from RNs and NPs, every day thousands of Nova Scotians interact with RNs and NPs and as a result, approximately 3% of our consultations each year are with employers, government and members of the public. If this is you, our Practice Consultants are also here to help you and they are only an email, phone call or meeting away.

Ask a Question
Practice Consultants

Jennifer Best
jbest@crnns.ca
Ext. 256

Trent MacIsaac
tmacisaac@crnns.ca
Ext. 250

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Q&A Featured Question

Standard 2: What is my Accountability When Changes in my Practice Area Impact my Practice?

"I am a RN working in obstetrics. Over the last several years, many of our young families have been leaving Nova Scotia to seek work and our birth rates have decreased as a result. My manager had a staff meeting this week and told us that because of this change in demographics, we would now we caring for urology clients in our unoccupied beds. How can I meet my standards of practice in this situation?"

Answer


As a RN, you experience changes in the health care system, such as a change in your client population on a daily basis that can have an effect on your practice.  As a part of meeting the 2017 Standards of Practice for Registered Nurses, you are accountable to reflect on changes in the healthcare system that may impact your practice environment.

For example, Standard 2 indicator 2.10 states that a registered nurse demonstrates knowledge-based practice by analyzing changes within the health care system that impact on their own practice and adapting appropriately. To meet this standard and indicator you will need to analyze the change and what it means for the care you provide. You may want to consider the following:

  • Why is the change happening?
  • How soon will the change take place?
  • How will this change impact my practice, the unit and the organization?

Once you consider these factors individually, it may be helpful to have a team meeting to discuss and share your thoughts and together, with a solution-focused approach, determine how care will be provided. As a team you may also want to consider:

  • How the care needs of the new population are different and how will we meet this need?
  • What knowledge, skills and abilities do we currently have that can contribute to this client population?
  • What new knowledge skills and abilities will we need to attain to care for this new population?
  • Where are our resources?

It is understandable that you may be nervous or unsure about how to proceed given that these changes will have a direct impact on your practice. However, as a self-regulating professional, you have the skills, abilities and resources available to analyze the environment, understand changes that may impact your practice, and modify your practice accordingly to provide quality care to clients. For more information, continue to explore Standard 2: Knowledge-Based Practice within the 2017 Standards of Practice for Registered Nurses.


Questions Archive


Standard 1: Accessing Resources Online - What Do I Need to Think About?

I am working with group of new breastfeeding moms and I have found some online videos which I think will be effective in supporting them to be successful. What do I need to consider if I want to use these videos in my practice?

On one hand, technology such as online videos can be a great teaching tool and support for clients. On the other hand however, the use of technology such as online videos may be perceived by clients as a distraction and this can have the ability to negatively impact the nurse’s connection to clients.

In the 2017 Standards of Practice for Registered Nurses, standard 1 indicator 1.10 outlines a nurse’s accountabilities when using technology in their nursing practice. Within this indicator, it states that a registered nurse demonstrates this standard by using technology (e.g. social media) responsibly and appropriately to enhance nursing practice. With this in mind, it is important to consider the following to ensure you are meeting this indicator:

Have you explored whether your clients would see this as a benefit or whether it would hinder the development of a therapeutic relationship? To gather this information, you should explain to the clients the benefits and/or risk associated with using online videos as a teaching tool.

Have you considered if your employer supports using online videos in practice? Are there organizational polices and procedures that support this practice? For example, there may be copyright issues with the use of the videos and you may need to consult your manager and/or your risk department.

What is the source of the videos and are they evidence-informed? There are many options online for clients and health professionals. As a nurse, you will need to determine if the source of the videos is credible. You could consult with library services or a local university to determine the creditability of the videos.

There is a wealth of information available online to help you and your clients in practice. However, as a leader and client advocate, you are responsible and accountable to the standards of practice to evaluate this information to help ensure that you are providing your clients with evidence-informed information that aligns with current best practice. This shouldn’t scare you away from accessing information online, as there are many benefits to client care, but there is an expectation for you to utilize the knowledge you have to help to ensure you are providing safe, competent and ethical care to all clients.

The Importance of a Comprehensive Nursing Assessment in the Development of the Plan of Care

Is a comprehensive nursing assessment important and if so, do I need to include the determinants of health? How does this assessment contribute to the plan of care, including the discharge plan?

Regardless of where registered nurses (RNs) practise, they are accountable to create a nursing plan of care. The nursing plan of care starts with an assessment of the client and identifies their needs, preferences and abilities and provides a benchmark for ongoing monitoring of their health status including presenting signs and symptoms. It provides the nursing team with the health and social history required for development of a comprehensive plan of care, which includes the discharge plan for that client (Standard 2.3). It also provides the RN with the foundation to work collaboratively with other health care team members and to coordinate client care.

A vital component of the nursing assessment is an assessment of the social determinants of health. The social determinants of health include income, spirituality, housing, food security, social supports, etc. When RNs complete a nursing assessment, they must include the determinants of health regardless of their practice setting in order to create a more comprehensive nursing plan of care based on the client’s individual needs and preferences.

When caring for clients in a variety of settings, including clients in a hospital setting, the information gathered during the nursing assessment supports the creation of a discharge plan that better meets each client’s unique needs.

For example, if an RN determines that a client cannot access services (i.e. physiotherapy) and treatments (i.e. medications) outlined in the medical plan of care because of their financial situation , these challenges could be identified in the nursing plan of care and a discharge plan may be put in place to better support the client. In this example, nursing interventions in the plan of care may include:

  • Collaboration with the physician related to the medical plan of care on the discharge plan;
  • Collaboration with the social worker to determine if the client qualifies for assistance in obtaining services;
  • Collaboration with the inpatient physiotherapist to determine a reasonable discharge treatment plan;
  • Collaboration with the pharmacist to determine if the client could be prescribed a more financially accessible medication;
  • Collaborating with the client to assist in identifying the social supports that family and friends may be able to provide.

Including the social determinants of health in the assessment and establishment of nursing interventions is a vital role for RNs and represent RNs working to an optimal scope of practice. For more information on the role of the RN in nursing assessment, the nursing plan of care or care coordination, please access the CRNNS Nursing Plan of Care Practice Guideline or contact a CRNNS Practice Consultant at practice@crnns.ca.

Ask a Practice Consultant- Caring for Syrian Refugees

I am considering providing support to the Syrian refugees who have come to Nova Scotia. What should I consider if I am thinking about providing nursing care to this client population?

Many refugees, such as those from Syria, may have been exposed to violence and war and lived for months or years in refugee camps in less than optimal living conditions.  As a result, many may have endured years of poor nutrition, inadequate health services and poor living conditions (CNA, 2010; ISANS). Thus, many refugees have unique health needs that need to be addressed.

Understanding the impact that a refugee’s social determinants of health have on their health and illness will support a more holistic approach to care by RN’s and NP’s.

The Transitional Health Clinic for Refugees is a great resource to use to learn more about the specific health needs of refugees. Resources from the clinic which you may find helpful include general information for successful integration into their new communities, as well as specific topics related to evidence-based clinical guidelines and immunizations.  They are also a number of videos on initial assessment, women’s health, cultural competencies, mental health and infectious diseases.  You might find some of the following links useful:

The videos can be found at this link.

The Canadian Nurses Association also has resources about providing nursing care to the Syrian refugees.  The following link takes you to their webpage:

https://www.cna-aiic.ca/en/on-the-issues/better-health/syrian-refugees

Refugees are best served when RNs and NPs understand their cultural context, are culturally competent and promote culturally safe health care environments (Standard 2, Indicator 2.8). Cultural competence is described as the provision of care within the cultural context of a client; congruent behaviors, attitudes and policies that come together to enable effective care in cross-cultural situations (CRNNS, 2012).

Recognizing that cultural differences exist, it is important to create a safe space for clients to feel comfortable to express their cultural beliefs and health care needs.  A culturally competent model, such as the Process of Cultural Competence in the Delivery of Healthcare Services, could be used to guide the client’s plan of care and ultimately, the provision of culturally competent care.

To support refugees such as the Syrian refugees in your role as an RN or NP, as either paid employees or as a volunteers, RNs and NPs must hold a current license with CRNNS.  If you currently do not hold a license and wish to either work or volunteer as an RN or NP, you may obtain a temporary license as long as you meet the eligibility criteria. Please note that volunteer hours as an RN or NP cannot be counted towards the required nursing practice hours for licensure.

If you do not qualify for a license, you still may be able to volunteer; however you cannot engage in the practice of nursing or represent yourself as an RN or NP. For more information on obtaining a license see the CRNNS website, email registration@crnns.ca or call 1.800.565.9744.

If you have a practice question about this topic, please contact us at practice@crnns.ca.

Emergency Room Coverage

I work in a small emergency department in rural Nova Scotia and we sometimes have closures because we don’t have physician coverage. What is my accountability to provide care when a client arrives to the department requiring emergent care but we have had to close because of a lack of physician coverage?

This is a great question about a potentially risky situation. In this type of emergency situation, if not providing care would lead to worse consequences than providing it, you have an accountability to assist the client.

When the client first arrives with an emergent issue you should complete a triage assessment, also known as a rapid patient assessment, to determine the client’s emergent needs.  Next, you will need to determine if there is another health care provider, in the facility, that more appropriately meets the client’s needs. For example, is there a physician who is doing rounds on the inpatient unit that could provide emergent care to the client? If no one is available to provide the client with care, you should call 911 and provide life sustaining care until Emergency Health Services arrives. You will be expected to act in accordance with your competence, standards and organizational policies to ensure that the client receives safe, competent care until s/he can be transferred to another health care professional or facility.
It is essential that organizational policies exist in order to support you and other RNs who may be found in this position. In instances where an organizational policy do not exist the RN has a duty to perform within their scope and competency (i.e. First Aid, CPR, and ACLS) until EHS arrives If policies do not exist this is an opportunity for you and your RN colleagues to become involved in the development of a current evidence informed policy so that your perspectives as leaders in the health care system are considered.

February 25th, 2016
Conduct Unbecoming

I have heard of the term conduct unbecoming in relation to a colleague who was acting in an unprofessional manner outside of the workplace. What is conduct unbecoming and can I really be held accountable for unprofessional actions outside of my place of employment?

Conduct unbecoming is defined in legislation as, “conduct in a member’s personal or private capacity that tends to bring discredit upon the nursing profession”.  This includes behavior in one’s private or personal life which is clearly inconsistent with the standard of integrity and professionalism expected of a registered nurse. Such conduct may reflect adversely on the nursing profession as a whole. If the conduct is such that knowledge of it would be likely to impair future clients’ trust in the nurse, CRNNS may be justified in taking disciplinary action.

Generally speaking however, CRNNS will not be concerned with the purely private or extra-professional activities of a nurse which do not bring into question the nurse’s professional integrity or competence.

Some examples of behaviour, which could be categorized as conduct unbecoming are described below:

  • Committing a criminal act that reflects adversely on the nurse’ integrity or fitness as a nurse, such as offences related to the illegal sale of controlled drugs and substances.
  • Providing unauthorized medications or treatments to former clients or family members.
  • Using public social media platforms in a way that does not uphold public trust in the nursing profession. Examples could include posting comments that provide inaccurate information on treatments or medication or publically posting disparaging comments about colleagues.

As member of the nursing profession, we are viewed as one of the most trusted professions, as people look to RNs for support and advice both inside and outside the workplace. You may feel that what you do in your personal life outside of work hours is your own business and it is; however,  we encourage you to think about how your behaviour and actions affect how you are viewed as a professional.

If you need help navigating a situation related to this topic, or you have questions about how actions outside of work can affect you as a professional RN, we encourage you to contact a CRNNS Practice Consultant at practice@crnns.ca.

New Grad and Charge Nurse

I am a newly graduated registered nurse (RN) and I just found out I passed the NCLX-RN exam! I now have a full active-practising license and my employer is asking me to take on the Charge Nurse role. I am worried I don’t have enough experience to take on this role. What should I do?

First of all, congratulations on your exam results and welcome to the nursing profession! As a newly graduated RN, you have unique needs that are different from those of the experienced RN and you need the support of your manager and other colleagues to be successful on your unit in any designated role, including the Charge Nurse role. Supportive practice environments that encourage you to feel welcome, safe, valued, respected and nurtured will ease your transition into practice and help support safe, ethical and quality health care.

To help new graduates like you transition to the profession, CRNNS has created a Transitioning to Professional Practice Toolkit and Module 8 of the tool kit gives you tips for a successful transition to practice. These tips can help answer your question and some of the key strategies to consider are explained below.

Communication/Stay Connected

  • Speak with your manager about your concerns. Let him/her know how you are feeling and offer a solution to the issue. For example, let your manager know that you don’t feel ready now to take on the Charge Nurse role but with some education, mentorship, orientation and support, you will be prepared to be ready to take on the role in the future.
  • Talk to colleagues who you have gradated with. Are they also being asked to be a Charge Nurse? How have they handled this? What education, orientation or mentorship are they engaged in? Their experiences can help you trouble shoot and come up with a realistic and practical solution.

Know your Limits and Stay Within Them

  • Know the limits of your practice capability during this period of transition. If you do not have the competencies to function in the role of Charge Nurse, let your manager know this and negotiate different assignment until you develop the competencies. If you are unsure of the competencies required and how you would obtain these discuss this with your manager. You should have a clear role description which should tell you the competencies required.

Adopt a Risk Management Approach

  • Talk to your manager and let him/her know you will need their support to progress slowly into any new roles and responsibilities as a newly graduated nurse.
  • Gradually and slowly advance your skills both clinically and as a Charge Nurse and ask your manager to limit the level of complexity of your assignment for the first four months. This will give you the time you need to become comfortable in your role as a newly graduated RN.

Reflect on your Practice and Ongoing Competence through CRNNS’s Continuing Competence Program

  • Reflect on activities as they happen, formulate and document strategies to address learning needs. Reflecting on your experience in preparing to take on the Charge Nurse role will be essential.
  • Use the CRNNS Continuing Competence Program to guide your self reflection, review and reflect on the Standards of Practice for RNs, develop a learning plan including goals, activities to achieve the goals and an evaluation plan.

Accept Accountability

  • Gain a sense of the roles, responsibilities and accountabilities expected of both a new graduate and of the Charge Nurse. As an independent practitioner, be responsible and proactive for yourself, your clients, and as a member of the health care team.
  • Review the role description your organization has for the Charge Nurse, look for trusted mentors for support, review any relevant literature. This will assist you in understanding and accepting accountability of the Charge Nurse role

When in Doubt, Ask

  • You may wish to debrief with a trusted experienced colleague, nurse educator or mentor about clinical situations you have encountered, including potential experiences as a Charge Nurse to gain understanding of leadership and decision making that happens in the Charge Nurse role.

If after attempting all these strategies your manager is insisting you take on the Charge Nurse role and you don’t feel as if you have the required competencies, it may be helpful for you to review the CRNNS Resolving Professional Practice Issues Toolkit. This tool consists of a five-step process that will assist you in solving a professional practice issue like this one.

The CRNNS Practice Consultants are always available to help you navigate situations like this; contact us at practice@crnns.ca.

For more information on what your manager can expect of the newly graduated RN, please see the following documents:

Employer - New Grad and Charge Nurse

I have hired a new graduate this spring and she just found out she has been successful in the NCLEX-RN exam. She no longer has a temporary license which had restricted her from functioning as a Charge Nurse. Now that she has a full active-practising licence, can I assign her to the Charge Nurse role?

Congratulations on your decision to hire a new nursing graduate!  Newly graduated registered nurses (RNs) have enthusiasm, current knowledge of best practice and will give your nursing team an opportunity to strengthen mentoring relationships. These benefits will only continue to grow when the newly graduated RN is supported in practice. Research has shown that support within practice environments is critical to professional growth, the consolidation of practice and retention of newly graduated RNs.

The newly graduated RN that you have hired has unique needs that differ from the needs of an experienced RN and they need your support to be successful on your unit in any designated role, including the Charge Nurse role. Supportive practice environments that encourage newly graduated RNs to feel welcome, safe, valued, respected and nurtured will ease their transition into practice and help support safe, ethical and quality health care. It is unrealistic to expect newly graduated RNs to function at the same level of practice as an experienced RN.

Due to the extra support that new graduates may need as they transition into practice, we do not encourage new graduates to immediately become Charge Nurses. As an RN Manager, you can instead support new graduates so they can build their competencies, confidence, knowledge, skills and abilities so they can eventually assume the Charge Nurse role. You can do this by:

  • Providing experiences that support newly graduated RNs to consolidate their knowledge application and skills, including leadership, to care for clients and the ability to take on leadership roles such as the Charge Nurse.
  • Providing specific Charge Nurse education and professional development through orientation, in-service education, and mentorship programs.
  • Encouraging and supporting experienced Charge Nurses to mentor newly graduated RNs as they begin to assume this role. They will need this continuous support to grow in the Charge Nurse role.
  • Providing clarity about responsibility and accountability of the Charge Nurse role, ongoing constructive feedback, and formal evaluation processes. For an example of Charge Nurse accountabilities and a role description, please click here.
  • Promoting an environment that encourages entry-level RNs to pose questions, engage in reflective practice, and ask for assistance without being criticized.

The Standards of Practice for RNs also discusses a supportive practice environment and the accountability you have as the RN Manager:

  • Standard 1, Indicator 1.12 states the nurse manager will promote quality practice environments that support best practices and the ability of registered nurses to practise safely, effectively and ethically.
  • Standard 4, indicator 4.16 states the nurse manager will promote practice environments that support staff to develop leadership qualities.

The newly graduated RN may not be ready today to take on the role of Charge Nurse yet but with your support guidance and leadership, before long she will be more than ready to take on this role.

For more information on what you can expect of the newly graduated RN, please see the following documents:

If you need more help with this question, we encourage you to contact a CRNNS Practice Consultant at practice@crnns.ca.

July 30th, 2015
Short Staffing

I work on a unit that has been chronically short staffed for the last few months.  I am concerned that my colleagues and I are not able to provide the care that is required to meet the needs of our clients and as a result, client safety could be impacted. What do I do in these situations to ensure that clients receive safe care and that I am able to meet my standards of practice?

Situations of short staffing can be an unsettling for registered nurses if they believe they are not able to provide the type of nursing care that they normally provide when the number of staff is insufficient to meet the needs of clients.

In situations like this, your first step and priority is to ensure that the immediate needs of the clients are safely met. The next step is to notify your manager or designate of the issue and work together to come up with a solution that ensures the ongoing client needs are met.

Step One: Ensure the Immediate Needs of the Clients are Safely Met

In these situations, you must work with the other members of the interdisciplinary team to:

  • Identify and prioritize the care that is required to meet the immediate and essential needs of the client
  • Determine what aspects of care can be safely assigned or delegated to other members of the team. (It is important to remember that you as the registered nurse are responsible for the appropriate assignment or delegation of nursing work, based on the client assessment to other members of the team).
  • Manage expectations of the health care team, clients and family.  One method is to notify clients and family that due to a higher than normal acuity level and/or insufficient staffing,   as a last resort they may notice that some of the care routines will change and reassure them that they will continue to have their essential needs met and receive safe care.

When situations of chronic short staffing exist, it is important that the RNs, other unit staff and the employer discuss the issue and determine strategies to address questions and concerns in both the short and longer term.  In situations like this, it is important that everyone work together to ensure that essential care is provided by maximizing the available human and technological resources.

When staffing is not sufficient to meet the patient care requirements, it is important to follow your organizational policies and processes about notifying and documenting  any short staffing situations for your employer.  In addition, if you are a unionized employee there may be additional documentation that is required.

Step two: Work with Others to Create Solutions

As solution focused professionals, registered nurses have the knowledge, skill and expertise and are in the best position to provide realistic and possible solutions to deal with a shortage of staff in both the short and longer term.  Examples  could include determining  how the collaborative healthcare team can work together to manage an increased workload due to higher than normal acuity levels or deciding to change the model of nursing care on a given shift to ensure that essential  is provided  when core staffing is not present.

Notifying your manager or designate of the staffing issue, as well as providing potential solutions, is a positive strategy to meet your standards of practice and to demonstrate and apply your leadership and solution-focused approach to client care.  A tool that may be helpful in working though these professional practice issues is the Resolving Professional Practice Issues Toolkit.

If you need help navigating a situation like this, we encourage you to contact a CRNNS Practice Consultant at practice@crnns.ca.

December 5th, 2014
Opposing Opinions on a Proposed Plan of Care

I work in a small community hospital with a close knit intraprofessional team. We are currently providing care for a client with complex physical and mental health concerns. Several members of our team are not in agreement with the proposed plan of care for the client. In fact, I am concerned that the plan of care could place the client at risk. What should I do?

This is a difficult situation for any health professional to face. As a registered nurse (RN), you have both a legal and an ethical duty to take action when a client is at risk based on either the actions or inactions of another RN or regulated health professional. According to the Standards of Practice for Registered Nurses (2012), nurses are obligated to take appropriate action in situations in which client safety and well-being is potentially or actually being compromised.

The College would advise that your first step is to determine if the proposed plan of care places the client at imminent risk. If the situation has put the client at imminent risk, you may need to intervene immediately to protect the patient. You must then report and document your concerns to your employer and/or the College. Through the support of our Practice Consultants, we are always available to assist you during difficult situations and provide you with the support you need. You may also want to refer to College documents Submitting a Complaint-Employer (2013) and Registered Nurses’ Duty to Report (2012).

If the proposed plan of care has a potential to put the client at risk and that risk is not imminent, the College would advise you attempt to address the issue with the team member who you feel is putting the client at risk through the plan of care. You should discuss your concerns with your colleague and focus the conversation on the potential risk the plan of care poses to the client. These conversations are never easy, but as solution-focused professionals, we have an obligation to have these discussions. The Resolving Professional Practice Issues Toolkit for Registered Nurses (2013) may assist you in framing this conversation. The goal will be to keep the client at the center of your discussion and offer alternatives to the proposed plan of care. If, after this discussion, the team member refuses to alter the plan of care and you still feel the client is at risk, you then have an obligation to discuss and document your concerns with your manager and the manager of the other team member involved, if applicable.

If, after this discussion there is still not a change in the plan of care and the client is still at risk, your next step would be to escalate the concern to the next level of management. These would be appropriate times to apply the skills and strategies from the Resolving Professional Practice Issues Toolkit. During these steps, it is important to inform your manager along the way so he/she can support you and the client you’re advocating for.

At this point, you may feel frustrated and helpless because you feel as if no one is listening to you. However, as an RN, your motivation to persist will be in knowing that you have an obligation to advocate for your clients and to ensure they receive the highest quality care.

If you’ve reported though the various levels of management without any change in the plan of care or if at any time the client is placed at imminent risk, you must report the team member to his or her regulatory body. According to the Standards of Practice for Registered Nurses (2012), nurses are obligated to report to employers and/or regulatory professional bodies concerns related to incompetence, professional misconduct, conduct unbecoming the profession, and/or incapacity of registered nurses and/or other healthcare providers.

If you need help navigating a situation like this, we encourage you to contact a College Practice Consultant at practice@crnns.ca.

The Canadian Nurses Protective Society (CNPS) is also a great resource for any practice questions related to a nurse’s legal obligation. CNPS has an infoLaw publication called The Nurse as an Advocate (2013) which will advise you on your legal obligations in situation like the one you have described. You can also contact CNPS for information, advice and education in the management of risks related to the delivery of nursing services.

Transporting Controlled Drugs in Rural Communities

As an RN, can I transport controlled drugs (ie: morphine) to clients in a rural community that cannot access a pharmacy?

As advances are made in the delivery of health services in communities, so are changes to the role of the registered nurse (RN). More clients are receiving care in their homes, such as palliative services, and this has posed challenges to the clients, their families and to the RNs delivering care. Some of the challenges are the result of rural communities not having a local pharmacy to access controlled drugs or the local pharmacy not being open when the client requires the drug. For example, a client who experiences a pain crisis at 9:00 p.m. may not be able to access the pharmacy to fill a prescription for the medication needed.

The need for RNs to transport controlled drugs in rural communities has been recognized as a barrier to practice and has recently been addressed by Health Canada. In October 2013, an exemption to the Controlled Drugs and Substances Act (1996) was released. Section 56 “Class Exemption for RNs Delivering Primary Health Care at a Health Facility in a Remote and/or Isolated Community” provides RNs with the authority to possess, provide, administer, transport, send and deliver controlled substances when providing primary health care services to patients located in a remote and/or isolated community, subject to the terms and conditions of this exemption. Any client that needs this service must be a patient of a district health authority or agency that is delivering the service. If you are not clear if this exemption applies to your practice setting, please speak with your management team.

The exemption does allow for the transportation of the controlled drug, but there are conditions that must be in place for this practice to occur. The client must be under professional treatment of the nurse, the controlled substance must be required for treatment by the client, the nurse must have a signed and dated order/prescription for the controlled substance and the RN must follow the policies and procedures for handling the controlled substance.

This practice is not without risk. The risk of the ability to maintain accurate drug counts, proper disposal and to protect the safety of the nurse all exist. We therefore advise you consider these risks when you consider implementing this practice in your district health authority or agency and to consult with your risk management team when developing policies related to this practice. There should be policies in place that clearly outline what processes the RN most follow, when counting , disposing narcotics, and provider safety considerations.

How should controlled drugs be stored safely in the client’s home?

In the hospital or long term care setting, controlled drugs and substances are kept in locked cupboards and are subject to regular inventory measures (e.g. periodic counts by nursing staff). While this requirement is clearly stated in legislation and regulations for health care facilities, these same regulations do not apply once the controlled substances are in the client’s home. Because a high percentage of drug diversion occurs from family member’s prescriptions, it is important that clients receive education on the best ways to safely store their prescribed controlled drugs in the home.

Registered nurses need to advise their clients to only keep the minimum amount of their controlled drug in the home; preferably by requesting a smaller supply from their provider or pharmacist. Diversion and theft of controlled substances occur more frequently when these medications are left in plain sight or there is open discussion about their presence in the home. Once in the home, controlled drugs and substances should be kept in a secure location, preferably a locked box or cupboard; with the key kept in the custody of a responsible adult.

How can unused controlled drugs and substances in the home setting be disposed of safely?

Similar to regulations and policies for storage of controlled drugs and substances, health care facilities also have policies on disposal of these medications; however there are no such mechanisms regarding disposal of controlled drugs and substances in the home once the medications are no longer required. As with any other prescription, individuals should not take or share a prescribed controlled drug that is not their own. Registered nurses need to advise clients to return any controlled drugs that are no longer required directly to a pharmacy for proper disposal.

March 27th, 2014
The Use of Mobile Devices for Information Sharing

I work in a rural health facility as an RN and recently, my RN colleagues and I have been asked by another health professional to photograph a previously diagnosed wound with our personal smart phones. The photo was to be sent to a consultant for his/her opinion regarding treatment options for the client. I’m not sure how comfortable I am with this or if I should be concerned about this process. Can you tell me the things I need to consider?

The internet and mobile devices – including smart phones – play an important role in our daily lives. As health professionals these tools may also be influencing the care we provide. Your question is an important one and it is also a question shared by many of your nursing colleagues.

Mobile devices like smartphones and iPads can be vital tools to support the provision of health care especially in rural health facilities. However, the use of these tools is not without legal and professional practice risk. These risks include potential privacy and confidentiality breeches, violations of professional boundaries and poor infection control practices (CNPS, 2013, CRNNS, 2012).

It is important to consider that mobile devices are not the only option available to RNs and other health care professionals. In fact, the College would advise that using the Telehealth technology that already exists in many locations throughout Nova Scotia would pose less risk. In addition, this technology could potentially be a better means for the consultant to assess the patient, which could result in a better outcome for the client. The Telehealth technology affords the health professionals an established practice with policy and even enables interaction with the client.

If the Telehealth technology is not available, it is advised that you share information via mobile devices with caution and ensure there are established organizational policies that address patient privacy and confidentiality standards. If your organization does not have policy related to sharing information via mobile devices it would be advised that you do not engage in this practice. You will need to discuss your concerns related to this practice and lack of policy with your manager. A resource that may be of assistance to you is the Resolving Professional Practice Issues Framework.

If your organization decides to engage in this practice it is advised that you become actively involved in the development of policies and procedures related to this practice that ensures clients receive safe competent, compassionate and ethical care from RN’s. Important factors to consider in policy development are;

  • Encryption of the device
  • Strong passwords
  • Storage of devices
  • Use of wiping software time out features
  • Infection control practices for devices
  • Consent to the photograph

It is not recommended that RNs uses their personal mobile devices. Instead, the College suggests that it would be best that an employer-issued mobile device be used for this practice.

For further information related to the legal risks of this type of practice, we recommend that you review the Canadian Nurses Protective Society’s infoLAW, “Mobile Devices in the Workplace” (November 2013).

As always, please don’t hesitate to contact one of the College’s Practice Consultants with any questions you might have. Please call Trent MacIsaac or Jennifer Best at 1-800-565-9744 or email practice@crnns.ca.

For further information about the use of social media please see the following College publications that were created to support registered nurses and nurse practitioners in Nova Scotia.

Social Media Guidelines for RNs and NPs

January 20th, 2014
RNs Floating to Other Nursing Units

During the holiday season the census on my unit is usually low and management requires that we float to other nursing units. What can I do to ensure clients receive safe care? Can I refuse to float?

Floating to other units to support the delivery of services is a common practice, which can lead to anxiety for you as a registered nurse (RN). Typically, RNs are hired by an organization and not a specific unit. This means that the RN has a contractual obligation to provide care to clients within the organization, which is not limited to the unit where the RN works.

Employers do have the right to re-assign you to another unit. In fact, they have an obligation to assign you if inadequate staffing on a particular unit puts clients at risk. In accordance with the “Code of Ethics for Registered Nurses”, you are bound to accept the assignment and collaborate with the nursing staff to enable priority adjustment to minimize harm (CNA, 2008).

The refusal of an assignment in an unfamiliar practice setting is only justified when the risk of harm to a client is greater by accepting the assignment than by refusing it (CRNBC, 2013). If you choose to refuse an assignment for any reason, you must inform your employer of the reason for refusal, document the decision-making process, and provide the employer with enough time to find a suitable replacement.

Accepting the assignment to float does not mean you are obligated to practice beyond your level of competence. Rather than refusing an assignment related to perceived lack of competence, you should negotiate the work assignment with your manager. This should be based on your individual scope of practice and competencies as a registered nurse. You should reflect on how you can meet your “Standards of Practice for Registered Nurses” while in this new practice setting, with consideration of the patient population, and communicate your needs and limitations related to this request (CRNBC, 2009). Every RN has many entry-level competencies (eg., carrying out client assessments, taking vital signs, assisting clients in activities of daily living) that are to be applied in any practice setting.

If you are asked to float to a clinical area that is unfamiliar to you, the College recommends that you follow these steps:

  • Ask the charge nurse or an experienced nurse for an orientation to the unit
  • Meet with the charge nurse to discuss your assignment. Inform the charge nurse of the care that you are competent to perform and care that you do not have the knowledge or skill to perform. You should then collaboratively develop a plan for client care for that shift.
  • Request an experienced nurse to be buddied with you for the shift.
  • Establish a plan for regular communication with the charge nurse/buddy to apprise them of any changes in clients care needs during the shift.

We know that floating to unfamiliar nursing units can cause some apprehension. These steps should help you feel more comfortable with this practice.

December 13th, 2013
Care Directive or Delegated Function?

I work in the Emergency Department and we want to create a protocol for patients who present with migraines. We’d like the protocol to include the initiation of an IV and the administration of medications after the RN assesses the client, but prior to the physician assessment.

Would this protocol be a ‘care directive’ or a ‘delegated function’? Also, what do I need to do to create the protocol?

This protocol would be considered a ‘care directive’, formally known as a ‘medical directive’.

A care directive (CD) is an order written by an authorized prescriber (a physician or nurse practitioner in your situation) for an intervention, or series of interventions, to be implemented by a registered nurse (RN) for a range of clients with identified health conditions, only when specific circumstances exist. The interven­tions outlined must be within the scope of practice of the RN who will be implementing the care directive. CDs can be implemented only when an authorized prescriber is available. Availability is to be determined by agency policy. The authorized prescriber holds ultimate responsibility in terms of ordering the intervention.

It is within the RN scope of practice to complete the required assessment for a patient presenting with a migraine, determine the appropriateness of the care directive, and initiate the care directive protocol by initiating the IV and administering the medication. As well, in an emergency department (ED) a physician would be readily available (either on-site or by telephone).  In this situation a care directive would be the correct approach to provide the patient with timely treatment for their migraine and would provide an opportunity for RNs to optimize their scope of practice as well.

Care Directive Development

Once it has been identified that a specific client need could be better met through the implementation of a care directive, the first step is to determine whether the required interventions are within the RN scope of practice and that the authorized prescriber sees a benefit in the development of the care. It is then time to start developing the CD by considering and answering the following:

  • the interventions that will be ordered by means of a CD;
  • whether an authorized prescriber is available;
  • the competencies required for the RN to perform the CD;
  • specific educational requirements
  • identification of the practice environment (specific units or services) in which the CD can be implemented;
  • identification of the authorized prescriber for whom a Care Directive applies. Some prescribers might not approve of a CD for their clients and, therefore, the nurse cannot use the CD with their clients;
  • documentation requirements for the RN performing the CD; and
  • development of a review and revision mechanism for the CD.

Once you have made these decisions you will need to document these decisions in a policy format which should include:

  • name and description of the intervention(s) being ordered;
  • specific client clinical conditions and situational circumstances that must be met before the intervention can be implemented;
  • identification of the healthcare professionals who can perform the CD;
  • a relevant assessment process to be used by registered nurses in making the decision as to whether to implement the directive;
  • specific monitoring parameters, and reference to appropriate emergency care measures;
  • identification of the contraindications to implementing the care directive;
  • name, date and signature of the authorized prescriber or the signature of an authorized prescriber who represents a group (e.g. department head could sign for a CD that applied to patients of all physicians under his/her service);
  • identification of any educational requirement(s);
  • date and confirmation of policy approval by appropriate approval body.

Once the CD has been developed it must be approved for use in your ED. Your employer must ensure that there is an appropriate approval body and processes to approve a care directive such as a Medical Advisory Committee (MAC) or an equivalent body. An equivalent body should consist of a representative authorized prescriber providing the CD, a representative RN involved in implementing the CD and other content experts – including representatives of risk management – as appropriate.

Additional Support

CRNNS has developed a document titled, “Care Directives: Guidelines for Registered Nurses”, to better support RNs to optimize their scope of practice and contribute to providing safe, timely, effective and efficient client care. See this document for further information or call one of the College Practice consultants at 1-800-565-9744 ext. 250 or 256 with any questions you may have.

Related Documents

Care Directives: Guidelines for Registered Nurses

Delegated Functions: Guidelines for Registered Nurses

November 18th, 2013
RN Assisting With Flu Immunizations

I have been approached by a local family physician to assist her to provide Flu Immunization Clinics in her office. What do I need to consider to ensure that I am meeting my standards of practice as a registered nurse? Am I able to provide vaccines to the office staff as well as the clients?

This sounds like an exciting opportunity to work in a collaborative way to provide care to your community. Before you start there are several things to consider.

Do you have the required competencies specific to immunization?

You first must determine if you have the necessary knowledge, skills and judgment to safely administer immunizations to the patient population you will be serving.These competencies include:

  • safe administration of the vaccine,
  • knowledge of the scientific basis of immunizations,
  • essential  immunization practices and contextual issues relevant to immunization.

For further information related to the competencies required to administer vaccinations please see “The Role of the RN/NP – Immunization – Q & A“.

What will your employment status be? Will you be an employee of the physician or will you be considered an external contracted service?

Regardless of whether you are an employee of the physician or are considered an external contracted service you must think about having an employment contract. The College advises you to contact The Canadian Nurses Protective Society for advice concerning the preferred type of employment status for your individual circumstance.

How will you get the order for the immunization?

Registered nurses can only administer immunizations when there is a direct order or care directive written by an authorized prescriber, which, in your case, is the physician. Without a care directive, you would not have liability coverage for the administration of immunizations. You will need to determine if the physician will see each patient and write an order or if a care directive can be developed in collaboration with the physician to enable you to use your knowledge, skills, and judgment to safely assess a client and administer the flu vaccine. For further information of Care Directives, please see the College’s publication, “Care Directives: Guidelines for Registered Nurses”.

Once you have determined you have the required competencies and an order (either for each individual or through a care directive) you may administer the flu vaccine to staff and/or volunteers within the office. If the physician’s office currently has a care directive, you can follow this. However, if the office you are working in does not have a care directive in place, you should follow the Nova Scotia Immunization Schedules as a care directive (endorsed by the Chief Medical Officer of Health).

Related Resource: The Role of the RN/NP – Immunization Questions & Answers

October 18th, 2013
Role of RNs in Cosmetic Procedures: BOTOX and Dermal Fillers

I am considering employment at a Medical Aesthetic clinic where I would be caring for clients who are being treated with BOTOX and/or dermal fillers. Is it within my scope of practice? If so, what things do I need to consider when caring for this group of clients?

The number of clients who receive cosmetic procedures involving BOTOX and dermal fillers is certainly on the rise in Nova Scotia. Registered nurses are not taught to perform cosmetic procedures in basic nursing programs and require a post-entry level competency. Post-entry level competencies require additional education and experience to ensure that the RN is competent. The RN also must follow a physicians’ order to carry out the procedure.

It is important to understand that these types of cosmetic procedures are not benign procedures and pose potential risk to clients including an increased risk of morbidity. Appropriate medical support must be readily available to deal with potential side effects, which could require interventions outside of the scope of practice of the registered nurse performing the procedure.

Care Directive Required

While RNs have the education and legislated authority to administer medications and/or substances by injection, a physician’s order, which could be in the form of a care directive, is required before an RN can administer any medications and/or substances, including BOTOX and dermal fillers. It is within the scope of practice of the RN who possesses the necessary competencies to administer BOTOX and dermal fillers with the appropriate amount of physician oversight.

When using a care directive, the prescribing physician maintains ultimate responsibility for the outcomes of these procedures regardless of the nature of the procedure or the type of facility in which they are performed. The RN maintains accountability for their decision to carry out the care directive for the particular client and for their competence in performing the procedure safely and competently.

For more information about care directives please refer to the College’s document titled, “Care Directives: Guidelines for Registered Nurses”.

Things to Consider

Nurses must have the appropriate competencies to perform cosmetic procedures involving BOTOX and dermal fillers. There must be an approved educational component demonstrating that the RN has obtained and maintained the required competencies. Registered nurses are expected to engage in ongoing professional development activities designed to maintain and increase their levels of knowledge and skill associated with cosmetic medical procedures.

The Role of Registered Nurses in Cosmetic Procedures: BOTOX and Dermal Fillers

BOTOX Dermal Fillers
1.    All clients requesting cosmetic procedures must initially be seen by the physician, who assesses the client, explains the risks and contraindications, obtains informed consent, marks the injection sites and prescribes the dosage. 1.   All clients requesting cosmetic procedures must initially be seen by the physician, who assesses the client, explains the risks and contraindications, obtains informed consent, marks the injection sites and prescribes the dosage.
2.   The physician must be on site for the initial injection of BOTOX. 2.   The physician must be on site for the initial injection of dermal filler.
3.   For subsequent treatments, the registered nurse can administer BOTOX by following a written care directive that includes an algorithm describing the dosage, location of the injection(s) and indications for injection. However, the physician must be readily available to consult on the treatment they have authorized. 3.   For subsequent treatments, the registered nurse can administer dermal fillers by following a written care directive that includes an algorithm describing the dosage, location of the injection(s) and indications for injection. However, the physician must be onsite to consult on the treatment they have authorized because of potential risks.
4.   A care directive should outline when further assessment by a physician is required, which would include when new injection sites or different doses are required for the client. 4.   A care directive should outline when further assessment by a physician is required, which would include when new injection sites or different doses are required for the client.

* It is important that the registered nurse and physician regularly collaborate to ensure that the plan of care remains appropriate.

The College’s Position Statement

To better support RNs working in settings where clients are treated with cosmetic procedures, the College has set out regulatory parameters for registered nurses to follow.For more information please see the College’s Position Statement titled, “The Role of Registered Nurses in Cosmetic Procedures: BOTOX and Dermal Fillers”.

Related Documents

Policy Regarding Care Directives in Aesthetic Medicine”, College of Physicians and Surgeons of Nova Scotia.

July 5th, 2013
Performing Pap Smears and Bimanual Exams

I am a registered nurse and as part of my practice I have been asked to perform Pap smears and bimanual exams. Is this within my scope of practice and if so what polices should be in place to support my practice?

A Pap test is considered a screening test and performing a Pap test is within the scope of practice of a registered nurse in Nova Scotia.

Bimanual gynecological exams are also considered within the scope of practice of the RN as long as the procedure is part of a screening examination of a well woman and not part of a diagnostic evaluation of a woman with severe pelvic or abdominal pain.

To support registered nurses to perform routine screening Pap tests and bimanual gynecological exams in well women, it is recommended that a short policy be in place that outlines:

  • the educational requirements for certification in bimanual exams and Pap tests. For example: Successful completion of the Pap Training Program offered through the Cervical Cancer Prevention Program (CCPP) at Cancer Care Nova Scotia
  • the follow up process for Pap results including when the results are abnormal or a physical exam indicates a potential abnormality.

The provincial PAP registry requires all registered nurses or other providers performing Pap tests to apply for a CCPP Registry ID number. This number ensures RN and other providers receive a Pap screening report card. The application process varies slightly depending on the location of the labs processing the Pap tests. To obtain a Pap Screening Report Card from CCPP it is important that the RNs name and Pap registry number be clearly identified on the cytology request form as well as the name of the client’s primary care provider or the well woman’s clinic receiving the report.

Whether your practice setting is a family practice office or a well women’s clinic, a primary care provider must be available for consultation and follow up for women with abnormal test results and a process must be in place to ensure women with abnormal Pap results are notified and arrangements are made for further investigation.

Availability of the collaborating NP or MD may differ depending on practice setting; each area of practice must define and communicate their specific definition of the term ‘available’.

References

Cervical Cancer Prevention Program. (2009). Screening for Cancer of the Cervix – An Office Manual for Health Professionals. Halifax, NS: Author.

Visit the Cancer Care Nova Scotia, Prevention and Screening, Cervical Cancer Prevention Program

March 28th, 2013
Writing Prescription Re-Orders: What is Acceptable?

I am a registered nurse and I’ve been asked to write prescription re-orders (re-fills) for a physician to sign. Is this an acceptable practice?

In a primary care setting the RN plays an important role in prescription re-orders and participating in medication reconciliation. Similar to when administering medications, the RN must have a sound knowledge of the medications the client is taking and is responsible for appropriate client assessment and client education.

The act of reordering a medication for the management of an established or chronic issue (referred by some as a medication refill) is a result of a clinical decision made by an authorized prescriber (physician, nurse practitioner) subsequent to an evaluation of a client’s response to drug therapy and the assessment of the continued need for the therapeutic effect of the medication. Although the prescriber may choose to accept a client assessment conducted by another health professional as the basis for reordering a medication(s), the prescriber always maintains the professional responsibility for prescription re-orders.

The central role of the RN is to provide the prescriber with appropriate client assessment findings to assist the prescriber in making an informed decision about the medication(s) being re-ordered. For example, the prescriber could use the RNs assessment to determine the ongoing appropriateness of the prescription reorder or to determine whether the client requires further assessment before the decision is made. Once the prescriber is satisfied they have sufficient information they could then reorder the medication.

In settings where an electronic medical record (EMR) is used it is acceptable for the RN to preprint the medication reorder for signature as long as the prescriber reviews the printed order prior to signing and makes an informed decision about the prescription re-order. Printing off the form is not equated with prescribing. The preprinting of a medication reorder reduces the risk associated with transcribing hand written orders. Transcribing hand written orders is not considered best practice because of potential for error in transcribing. However, the preprinting of orders under the conditions described above is acceptable and facilitates collaborative practice.

The discussion of the client’s assessment between the RN and the prescriber, related to the prescription reorder would be best done in the presence of the client. In the event that this is not possible the client must be informed that the RN has discussed their assessment with the prescriber and that the decision to re-order the medication(s) was made by the prescriber. The RN would document that pertinent assessment data was discussed with the prescriber and that the prescriber reordered the medication. The RN would also document the client education provided

References

College of Registered Nurses of Nova Scotia. (2011). Medication Guidelines for Registered Nurses. Halifax, NS: Author.

College of Physicians and Surgeons of Nova Scotia. (2008). Policy regarding Prescribing Practice/Countersigning Prescriptions/Internet Prescribing. Halifax, NS: Author.

Department of Health and Wellness. (2011). Memo: Electronic Medical Records (EMR) and Documentation by Registered Nurses. Halifax, NS.

March 28th, 2013
Family Practice Nurse Working Independently in Physician's Office

I’m an RN working with a family practice physician. Is there anything I can do independently without the physician participating in the visit?

The College recognizes that working as part of a collaborative team in a family practice setting, a registered nurse enhances access and quality client care. Additionally, there is evidence that, when the RN scope of practice is optimized, use of a family practice nurse improves health outcomes within the practice. According to the RN Act (2006), registered nurses can independently assess, plan and coordinate care, provide guidance and counseling, monitor and adjust the plan of care, make referrals to other health providers and community resources and evaluate clients’ response to treatment.

Many family practice nurses are employed in a physician’s office where a physician bills MSI for services conducted jointly by the FPN/physician team. As MSI is restricted to physician billing, services rendered by a registered nurse are not billable unless:

“All insured services claimed must reflect services rendered personally by the physician in an appropriate clinical setting. The physician may claim for visits conducted partially by the nurse only if the physician has personally participated in the visit and this is reflected in the clinical note. A signature or electronic sign off of the chart is not considered sufficient documentation of direct participation in the visit.” (MSI Physicians’ Bulletin, volume XLVIII – #2)

When the physician directly employs the family practice nurse, the following procedures and interventions performed by the nurse can be billed without the physician interacting with the patient:

  • Pap examination
  • Immunizations
  • Influenza vaccine
  • Other injections (e.g., B12, Enbrel)

The College is supportive of family practice nurses optimizing their scope of practice but recognizes the importance of being clear of the current MSI billing processes.

December 21st, 2012
Assignment and Delegation

I work in a long term care facility with unregulated care providers and I am confused about the difference between assignment and delegation. Can you help me clarify these concepts?

Absolutely. As the delivery of health care continues to evolve towards inter-professional practice, a variety of healthcare professionals are expected to collaborate and work together to provide better health care for Nova Scotians. Understanding assignment and delegation is especially important as collaboration with unregulated care providers (UCPs) is becoming an increasing part of nursing practice.

What is an assignment?

An assignment is the allocation of clients or client care responsibilities/interventions that are within the provider’s scope of practice and/or scope of employment. Assignment describes the distribution of work that each staff member is to accomplish.

Determining work assignments is a dynamic process where decisions are evaluated and adjusted as the healthcare team works together to meet the changing needs of clients. Assignments are determined according to:

  • The client’s condition (complexity, variability, acuity)
  • The health provider’s scope of practice
  • The scope and/or competence of the healthcare provider performing the intervention
  • The scope of employment and/or agency policy
  • Context of practice.

When client care is assigned to an RN they may perform the assignment autonomously because they are accountable for their own actions and decisions. When client care is assigned to a UCP, the UCP is accountable to implement the assigned task safely and competently within their scope of practice/employment.

Prior to assigning a client or intervention, the UCP’s competence must be considered. For example, if the task is within the UCP’s role description but s/he does not have experience performing the task, the RN may need to consider the appropriateness of the assignment. The RN is responsible for the ongoing assessment of the appropriateness of the assignment as well as for the ongoing assessment of the client’s health status and plan of care.

The RN assigning the task to the UCP is always responsible and accountable for providing appropriate supervision and feedback.

What is delegation?

Delegation is transferring an intervention that is within the scope of practice of one healthcare provider to another healthcare provider for whom the intervention falls outside of her/his scope of practice/employment. Delegation does not involve transferring accountability for the outcome of the function or intervention although the delegatee is responsible to successfully perform the intervention. It is important to remember that delegation only takes place when it is determined to be in a client’s best interest.

Delegated interventions are considered for those clients who are stable with predictable outcomes, there is minimal potential risk and the intervention does not require application of the nursing process. As client outcomes become less predictable, the RN is less likely to delegate the intervention.

When deciding to delegate to a UCP, the following factors must be considered:

  • What is included in the UCP scope of practice and scope of employment.
  • The UCP has sufficient education, is competent to perform the delegated intervention and is supported by employer policy.
  • Delegation is always client-specific and not transferable to another client.
  • RNs must understand the definitions of activities of daily living (ADLs) and instrumental activities of daily living (IADLS) as they apply to the UCP role. The RN assumes responsibility for the delegation, supervision and evaluation of the UCP’s competence and provides corrective action when needed.
  • If a client’s status changes, the RN must rely on her/his professional judgment to assess the situation and ensure the client receives safe and effective care.

Supervision is an essential component of assignment and delegation processes. There is no delegation and/or assignment without proper supervision, monitoring and evaluation of client outcomes. Supervision can take a variety of forms which range from direct (where the RN is physically present and directly observing) to indirect remote (where the RN is available but not physically present). The level of supervision is determined by the client care need, the education and experience of the UCP and the predictability of outcomes.

For more information on assignment and delegation, please refer the College’s Assignment and Delegation Guidelines.

November 20th, 2012
Camp Nursing

I’m an RN who has been offered a position as a camp nurse for three weeks this summer. I’m excited about the opportunity but I’m also concerned about meeting my standards of practice in this unfamiliar practice environment. Is there anything I should know ahead of time?

Generally, practising in a camp setting means that you work autonomously as an RN outside of a healthcare facility and often without other healthcare providers. The camp environment offers a unique model of care delivery and, as a result, camp nurses require the competence to practice in this setting.

Regardless of the practice setting, you, as an RN, are accountable to practise in accordance with your Standards of Practice for Registered Nurses and Code of Ethics and you also need to be aware of provincial regulations that could relate to your role as a camp nurse. Ensuring the camp has policies and protocols in place will be an important factor in enabling you to meet your standards.

The responsibilities of camp nurses vary from camp to camp but the role primarily consists of helping campers meet their health needs, preventing injury and providing care in emergency situations. Before you accept the position as camp nurse, the College recommends that you review the job description and discuss any concerns you might have with the employer.

The following are some factors you should consider when practising nursing in a camp setting:

  • If a physician is not on-site you may find yourself in a position of providing interventions that are outside your scope of practice. The camp should have medical directives related to common health problems and/or interventions (eg., heat stroke, anaphylasix, minor injuries, etc.). You should also know how to access a physician if necessary and what support might be available from other healthcare professionals.
  • One factor you should consider is liability coverage as a camp nurse. Does the camp have policies on liability insurance? The Canadian Nurses Protective Society (CNPS) provides liability protection for licensed registered nurses who are members of the College and this protection would be available to you if you are paid – or volunteering – as a camp nurse. For more information on liability protection or coverage that you might require as a camp nurse, contact CNPS at 1.800.267.3390 or visit www.cnps.ca.
  • As is required in any practice setting, you would be expected to document nursing care provided as a camp nurse. You would also be responsible for reviewing and updating campers’ health records.
  • As a camp nurse, you may be required to administer medication and, as is the case in any practice setting, you would be expected to have current knowledge of all medications and treatments being administered. This would include knowing camp policies specific to the collection, storage, distribution and administration of medications.
  • You must also be registered as a nurse in the province in which you are practising. Camp nursing is often described as rewarding by RNs who have experienced it themselves and it may help you develop skills that are beneficial to other practice settings.

For more information about camp nursing refer to the “Camp Nursing Practice Guidelines“.

November 8th, 2012
Accepting Orders from Out-of-Province Physicians

Can a registered nurse accept an order from a physician who is not licensed to practice medicine in Nova Scotia and lives in another province?

There are instances in which registered nurses encounter clients that have been treated outside of Nova Scotia and bring with them medical orders from out-of-province physicians. In this situation, the needs of the client are considered best-served through the pre-established relationship with their physician who practices outside of Nova Scotia. You, as the RN, may accept an order from the out-of-province physician as long as that physician has a pre-established relationship with the client and the RN/employer has verified that the physician is licensed to practice medicine in the home province.

The following examples demonstrate when these circumstances may occur:

  • Nova Scotians who live close to the border of New Brunswick may receive medical orders after being treated by a New Brunswick physician and require home care upon returning to Nova Scotia.
  • Individuals who come to Nova Scotia for a short period of time (e.g., vacation, work contract, school) may require home care for a pre-existing health issue for which they have a medical order from an out-of-province physician.
  • Individuals permanently moving to Nova Scotia may require care for a pre-existing condition for which they have a medical order from their out-of-province physician. While the individual seeks a physician in this province, it would be appropriate for you, as the RN, to accept orders from the out-of-province physician. The client should be encouraged to find a family physician in Nova Scotia as soon as possible and a transfer of care should then occur between physicians.

While the above scenarios all differ slightly, the same principle applies. The health care needs of the client are best served by a physician who has a pre-existing relationship with the client, rather than by a physician in Nova Scotia who has no prior knowledge of the client.

From the perspective of the College, RN employers should have policies/processes in place to:

  1. verify physician licensure in the other province,
  2. enable the RN to contact the physician if s/he has a question about the client’s care or the orders,
  3. utilize if the patient requires immediate care by a physician. In this situation the RN should send the client either to a walk-in clinic or emergency department depending on their assessment and the immediate needs of the client

June 12th, 2012
RN Role When Working in Triage with LPNs

I am a registered nurse (RN) working in an emergency department and licensed practical nurses (LPNs) are part of the triage process in my facility. What is my role as an RN when working with LPNs in triage?

In the triage role, the nurse’s responsibility is to assess the urgency of care needed by the client. It is impossible to predict how many clients will present to the emergency department and what their health care needs will be. Consequently, the stability of the environment and client care needs, as well as the predictability of the client conditions or outcomes, is uncertain and varied. As a result, the triage nurse requires in-depth assessment, critical thinking and decision-making skills.

When there is a lack of qualified RNs available to triage all clients, LPNs may participate in the triage process. In this situation, the LPN must consult with you, as the RN in the emergency department. Only LPNs who have completed a formal Canadian Triage and Acuity Scale (CTAS) course, a minimum education standard for LPNs working in this capacity, are able to complete a triage assessment (otherwise known as a rapid patient assessment) and health history, which will determine a preliminary CTAS score. It is your role, as an RN who has likewise completed a recognized CTAS course, to review the data provided by the LPN, validate the assessment findings and confirm that the CTAS score is consistent with the presentation of the client. A final CTAS score is assigned once the LPN has consulted with the RN for interpretation of the findings.

If, after consultation, the RN does not change the CTAS score assigned by the LPN, the agreed upon score is recorded. If there is a difference between the CTAS scores assigned by the LPN and RN, it is the RN’s CTAS score that is considered final, documented and used for client care planning. For that reason, if the RN has concerns regarding the preliminary assessment of the client and feels conditions may have changed or further consideration may be required, the RN must do a more in-depth assessment to ensure the assessment is accurate.

When working with LPNs in triage, the RN is responsible to determine the overall predictability and/or complexity of the client based upon determination of the final CTAS score. The LPN is accountable for her/his own practice and is expected to consult with you, as the RN, immediately for CTAS scores of 1, 2, or 3. For a CTAS score of 4 or 5, the LPN is required to consult with the RN within 30 minutes.

April 17th, 2012
Refugees

I have been hearing so much in the media about the upcoming arrival of the Syrian refugees to Nova Scotia and I want to offer my help. What should I consider if I am thinking about providing nursing care to this patient population?

This population will have unique needs due to their experiences. Registered nurses (RNs) and nurse practitioners (NPs) are in a position to use their knowledge, skills and abilities to support newcomers to our province.

Refugees, such as those arriving from Syria, may have been exposed to violence and war and as a result, may have endured years of poor nutrition, inadequate health services and poor living conditions (CNA, 2010). Their health experience and ability to access health services will continue to be influenced by the determinants of health such as culture, religion, language, housing and finances.

First and foremost, understanding the impact that a refugee’s social determinant of health may have on his or her health and illness will contribute to our abilities as RNs and NPs to support a holistic approach to care.  For more information on the specific health care needs of refugees, please contact the Transitional Health Clinic for Refugees which gives health care professionals access to a variety of resources specific to this topic.

According to the Standards of Practice for RNs, each RN is accountable to demonstrate cultural competence and promote culturally safe environments for members of the health care team and the public (Standard 2, Indicator 2.8). Cultural competence is described as the process by which RNs and NPs continuously make every effort to deliver nursing care effectively within the client’s cultural context (Campinha-Bacote, 2011).

RNs and NPs who would wish to support Syrian refugees in Nova Scotia need to consider how the refugees’ experiences and culture have impacted and will continue to influence their health.  RNs and NPs must recognize that cultural differences exist and explore these issues with clients. They must for example, create a safe space for clients to feel comfortable to express their cultural beliefs and needs. To culturally assess their clients’ needs, RNs and NPs should use a culturally competent model, such as the Process of Cultural Competence in the Delivery of Healthcare Services to guide the client’s plan of care and ultimately, the provision of culturally competent care.

RNs and NPs who wish to support the Syrian refugees as either paid employees or as volunteers in the capacity of an RN or NP must hold an active-practising license with CRNNS.  If you currently do not hold an active-practising license and wish to either work or volunteer as an RN or NP, you may be eligible to obtain a temporary license as long as you meet the eligibility criteria. Please note that volunteer hours as an RN or NP cannot be counted towards the required nursing practice hours for licensure.

If you do not qualify for an active-practising or temporary license, you may still be able to volunteer to help; however you cannot engage in the practice of nursing nor can you represent yourself as an RN or NP. For more information on obtaining an active-practising license or a temporary license see the CRNNS website, email registration@crnns.ca or call 1.800.565.9744.

If you have a practice question about this topic, please contact us at practice@crnns.ca.

December 22nd, 2015
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