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Nurse Practitioner Standards of Practice

The Nurse Practitioner Standards of Practice is a guide that shapes the professional practice of all NPs in Nova Scotia. We regulate the practice of nurse practitioners, who are professionally, ethically and legally accountable to practise according to the standards, and so ensuring the standards are met is a collaborative effort between us and the nurse. The standards are used to:

  • Guide the professional knowledge, skills and judgment needed to practise nursing safely
  • Sets the professional and legal boundaries for nursing practice
  • Describe the performance expected of NPs in their practice

The Nurse Practitioner Standards of Practice are broad profession-wide standards and form the foundation for all other nursing standards. NPs must adhere to both the Nurse Practitioner Standards of Practice and the Standards of Practice for Registered Nurses.

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The Standards

Standard 1: Responsibility and Accountability

Nurse Practitioners are responsible and accountable for providing competent, safe and ethical care within their legislated scope of practice. In terms of specific functions, nurse practitioners are responsible and accountable for assessing, diagnosing, treating, managing, monitoring and evaluating clients’ health conditions. They perform these functions in accordance with their educational preparation, competence and focus of practice.

1.1 Practise according to ethical, legislative and professional standards that reflect their increased level of responsibility, accountability and scope of practice.

1.2 Notify the CRNNS when considering changing their patient population and/or practice setting and, as required, successfully complete the CRNNS’s Competence Assessment Program for nurse practitioners.

1.3 Provide only those health services that legislation, standards or policies grant them authority to perform and for which competence has been achieved and maintained. The only exception is in life-threatening emergency situations. In such situations, nurse practitioners are ethically obliged to provide the best care they can within the constraints of the circumstances.

1.4 Base treatment decisions on the best evidence that appropriate sources can provide, as well as their own clinical judgment and their clients’ needs, while considering client preferences.

1.5 Practise autonomously and collaboratively as a member of an interprofessional team.

1.6 Document all aspects of client care as required by legislation/regulation (federal/provincial/territorial) and policy (CRNNS and employer).

1.7 Maintain, store and transfer client health records according to legislation/regulation (federal/provincial/territorial), professional standards and relevant policies.

1.8 Arrange for another professional(s) to provide care for clients who need urgent, continuous and/or follow-up care during times when the nurse practitioner will be absent.

1.9 Recognize and address situations that place them in a conflict of interest, and take steps to avoid any actions or situations that could put them in a conflict of interest.

1.10 Recognize and address breaches of legal, ethical and practice standards, made by themselves or by others, in a timely and appropriate manner.

Standard 2: Leadership and Advocacy

Nurse practitioners have a leadership role in the healthcare system. They work collaboratively with other healthcare professionals and policymakers to influence policy decisions that affect health services and the allocation of resources. They advocate for their clients’ needs within the healthcare system. Through leadership, nurse practitioners enhance the quality of client care and improve the delivery of health services within their focus of practice.

2.1 Identify, implement and evaluate strategies to improve healthcare services and resulting health outcomes for the clients and communities they serve.

2.2 Work with communities and other healthcare professionals and stakeholders to identify and advocate for health services and resources that are needed in the communities they serve.

2.3 Develop, implement and evaluate targeted health promotion and injury prevention activities for individuals, families, communities—and specific age and cultural groups—as appropriate to their focus of practice.

2.4 Contribute to the development of standards, practice guidelines and policies related to nurse practitioner practice.

2.5 Identify policies and procedures that need to be created or revised to improve client care, and take part in developing and/or revising these policies and procedures.

2.6 Contribute to evidence-based practice by participating in research, sharing information, and educating peers, other health professionals, clients and communities.

2.7 Educate the public, employers and other health providers about the role of nurse practitioners, and share evidence of nurse practitioners’ contributions to improving health services and client outcomes.

2.8 Act as role models and mentors to registered nurses, other nurse practitioners, students and other health professionals within the healthcare team.

Standard 3: Continuing Competence

Nurse practitioners are responsible for maintaining and enhancing all of their current competencies. At the same time, they must continue to develop new competencies that are relevant to the scope and context of their practice and equip them to serve their particular client population better.

3.1 Pursue and complete continuing education appropriate to their focus of practice.

3.2 Acquire theoretical knowledge of new skills and procedures and practise under qualified clinical supervision before performing them independently.

3.3 Demonstrate up-to-date knowledge and the ability to critically appraise information about therapies, best practices, guidelines and resources pertaining to their focus of practice.

3.4 Participate in the CRNNS’ Continuing Competence Program (Building Your Profile™). This involves an annual process of reflecting on their own practice, seeking feedback from other members of the healthcare team, determining their own learning needs, developing and achieving learning objectives, and keeping a record of their efforts to build their competence.

3.5 Propose and negotiate opportunities to enhance their knowledge and skills.

3.6 Fulfill the requirements of the Nurse Practitioner–Quality Monitoring & Improvement Program™ and take the initiative to improve their practice based on their results.

Standard 4: Assessing, Diagnosing and Monitoring

Nurse practitioners assess, diagnose, treat and monitor clients with acute and chronic physical and mental health conditions, using a variety of techniques, tools and sources of information. In providing this care, nurse practitioners take a person-centered approach that engages clients in identifying their health needs, understanding their options and making choices about their health. Nurse practitioners’ therapeutic management is informed and guided by the best available evidence and understanding of the holistic nature of health and social determinants of health.

4.1 Perform comprehensive or focused assessments that are appropriate to a client’s situation. This can include taking a history, performing a physical examination and/or reviewing reports of other health professionals’ assessments, investigations and findings.

4.2 Determine clients’ health risks and differential diagnoses, based on the findings of their assessments, to guide them in their decisions regarding further investigations, ongoing monitoring, and consultations with other professionals.

4.3 Select screening, diagnostic and monitoring tests based on best-available evidence, best practice guidelines, and provincial and organizational policies and standards. This includes considering the risks, benefits, appropriateness and cost-effectiveness of potential tests.

4.4 Discuss with clients the purpose and risks of screening and diagnostic tests, and why the findings might be important to that person’s health.

4.5 Order and interpret diagnostic tests, according to the Nurse Practitioners’ Authorized Practices: Nova Scotia Schedule of Screening and Diagnostic Tests, to identify and monitor client health risks, and to diagnose and monitor acute or chronic physical or mental health conditions.

4.6 Establish a systematic and timely process to receive, document, track and communicate test results.

4.7 Formulate definitive and working diagnoses and consider their potential implications, treatment plans and expected outcomes/prognoses, based on the overall health status of clients.

4.8 Communicate diagnoses, potential implications, treatment plans, expected outcomes and overall prognoses in a sensitive, honest and respectful manner that anticipates and responds to clients’ feelings and concerns.

Standard 5: Prescribing and Monitoring the Therapeutic Treatment Plan

Nurse practitioners are responsible for prescribing safe, effective and appropriate pharmacological and non-pharmacological therapy when assessments, investigations and clients’ situations indicate that therapy is desirable or necessary. These therapies include pharmaceuticals, blood/blood products, medical gases, alternative therapies, health programs and service and related healthcare equipment/supplies for clients with acute and chronic health conditions. Nurse practitioners actively engage clients in the process of deciding what therapeutic options to pursue in their situations, and respect their clients’ choices about therapies

5.1 Prescribe medications according to ethical and professional standards, federal/provincial/territorial legislation, regulations and policies, and organizational policies.

5.2 Prescribe medications according to the Nurse Practitioners’ Authorized Practices: Nova Scotia Schedule of Prescribing Pharmaceuticals and considering financial implications to the client in the context of the current public and private third-party insurers’ reimbursement parameters.

5.3 Prescribe and monitor pharmacological and non-pharmacological therapies according to research evidence and the most up-to-date guidelines for best clinical practice.

5.4 Evaluate the evidence for the therapeutic benefit and cost-effectiveness of pharmacological and/or non-pharmacological therapies.

5.5 Examine marketing strategies used to promote health products, medical devices, medications, alternative therapies and health programs, and consider their potential influence on prescribing patterns.

5.6 Counsel clients on prescription and non-prescription drugs and cost-effective alternatives, including rationale, expected effect, potential side/adverse effects, interactions with other substances, precautions specific to the drug or clients, reasons to adhere to the prescribed regimen (dose, frequency, duration), and required follow-up.

5.7 Monitor clients’ responses to drug therapies and continue, adjust, or discontinue a drug based on their observations of these responses.

5.8 Complete prescriptions, in writing or otherwise, according to the Nova Scotia Practice of Pharmacy Regulations (2003) and other relevant legislation, standards and policies.

5.9 Discuss potential benefits and risks of alternative or complementary therapies with clients as appropriate.

5.10 Document the rationale for pharmacological and non-pharmacological therapies and expected treatment outcomes.

5.11 Document and report adverse events associated with pharmacological and non-pharmacological therapies according to federal/provincial/territorial legislation, regulation and policy, and organizational policy (e.g., Canadian Adverse Drug Reaction Reporting Program).

5.12 Refrain from prescribing pharmacological therapy for themselves or family members, except to intervene in an emergency situation or to treat a minor/episodic condition when there is no other prescriber available.

Standard 6: Invasive and Non-Invasive Procedures

Nurse practitioners are responsible and accountable for performing both non-invasive and invasive procedures for which they have developed and maintained competence. Nurse practitioners perform these procedures in a safe, competent and ethical manner in order to assess, restore and maintain client health.

6.1 Perform non-invasive and invasive procedures in accordance with the Nurse Practitioners’ Authorized Practices: Nova Scotia Schedule of Procedures.

6.2 Communicate the evidence-informed rationale for proposed invasive and non-invasive procedures, so that clients can make informed decisions; taking into account clients’ needs and circumstances, expected therapeutic effects, contraindications, risks, precautions and required follow-up.

6.3 Obtain and document clients’ informed consent (verbal and/or written) prior to performing procedures, when required.

6.4 Anticipate and safely manage potential unintended procedural outcomes.

6.5 Monitor, evaluate and document clients’ responses to and outcomes of procedures.

Standard 7: Collaboration, Consultation and Referral

Nurse practitioners collaborate, consult with and refer clients to the most appropriate health professional when they determine that another professional’s expertise is required for competent and safe client care. Prior to acting on advice from other health professionals, nurse practitioners are require to evaluate these recommendations in light of a client’s current situation and healthcare preferences. In addition, nurse practitioners accept referrals and requests for consultation from other healthcare providers and are accountable for the advice and recommendations they provide. Consultations may occur in person, by telephone, in writing or electronically, as appropriate to individual situations.

7.1 Establish a collaborative practice relationship with a physician or group of physicians based on the Guidelines for Collaborative Practice Teams and Employers of Nurse Practitioners. They submit a Collaborative Practice Relationship Verification Form when entering or leaving a practice and when changing collaborating physicians or client populations.

7.2 Establish collaborative relationships and networks with other healthcare providers and organizations, as appropriate to the nurse practitioner’s focus of practice.

7.3 Recognize the need for consultation and/or referral and initiate requests in a timely manner when the expertise of another health professional or agency is required for safe and effective client care.

7.4 Discuss the nature, rationale and expected outcomes of proposed consultations and referrals with clients.

7.5 Approach the most appropriate healthcare professional(s) for consultation or referral when a client’s care requirements exceed the nurse practitioner’s competence or scope of practice.

7.6 Consult with and/or refer to a physician when a client’s health condition is unstable or likely to destabilize/deteriorate, or when signs, symptoms and/or diagnostic tests suggest a systemic infection, vital-organ obstruction, and/or potential threat to life, limb or senses.

7.7 Communicate and document the reason, level of urgency and expected action from consultants (e.g., opinion, recommendation, shared care, transfer of care) when requesting a consultation or referral.

7.8 Evaluate advice and recommended treatment plans from other healthcare professionals, including consultants, and discuss the recommendations with clients.

7.9 Accept referrals and requests for consultation from other healthcare providers and provide advice and recommendations based on their knowledge, individual competence and focus of practice.

7.10 Clearly communicate and document the advice and recommendations they provide when responding to requests for consultations or referrals.

Standard 8: Legislative and Regulatory Standards

Nurse Practitioners are knowledgeable about the federal and provincial legislation and regulations relating to the management of controlled drugs and substances. The following legislative and regulatory standards apply to prescribing for all controlled drugs and substances.

8.1 Prescribe controlled drugs and substances according to relevant legislation, standards and policies

8.2 Complete prescriptions for controlled drugs and substances in the form approved by the Prescription Monitoring Program Board, and in accordance with the Nova Scotia Pharmacy Act and Regulations, the Prescription Monitoring Program Act and Regulations and other relevant legislation, standards and policies.

8.3 Adhere to guidelines regarding safe storage and transportation of controlled drugs and substances if required in their focus of practice.

8.4 Complete initial Controlled Drugs and Substance education requirements as set out by the CRNNS.

Standard 9: Clinical Standards for Prescribing Controlled Drugs and Substances

Nurse practitioners are responsible for prescribing controlled drugs and substances in a safe and effective manger when assessments, investigations and diagnoses indicate that this therapy is appropriate. In addition, nurse practitioners actively counsel their clients regarding safety of controlled substances; taking into account their client’s personal situation and social determinants of health. Controlled drugs and substances include agents listed under the Controlled Drugs and Substances Act.

9.1 Prescribe controlled drugs and substances based on evidence, best practice and current clinical practice guidelines appropriate to the NP’s focus of practice.

9.2 Complete a comprehensive assessment of the client’s diagnoses, history of previous controlled drugs and substance use verified through PMPs E-access patient profile portal, comorbid conditions, prescribed medications (both controlled drugs and substances and other medications), other nonpharmacological
therapies, psychosocial, psychiatric and substance use history, and risk assessment for addictive behaviours.

9.3 Develop a holistic and individualized plan of care in conjunction with the client and other health care team members.

9.4 Negotiate, document and communicate a treatment agreement with the client and other designated prescribing providers; and register the treatment agreement with the Nova Scotia Prescription Monitoring Program when indicated.

9.5 Monitor clients’ response to prescribed controlled drugs and substances after initial trial and on a regular basis, using evidence-informed assessment tools.

9.6 Revise the plan of care by continuing, adjusting, weaning or discontinuing the prescribed controlled drugs and substances; based on client’s therapeutic response, expected treatment outcomes, adherence to treatment plan, aberrant drug behavior, current evidence, and potential for misuse or diversion.

9.7 Maintains knowledge of current evidence and best practice related to prescribing of controlled drugs and substances.

9.8 Collaborate with the health care team and other stakeholders in the development and evaluation of controlled drugs and substances prescribing practices within focus of practice; considering their impact at the individual, family, and community level.

9.9 Collaborate in the development of safety measures for prescribers and other staff to address increased risks associated with prescribing controlled drugs and substances, including methods to provide for a safe working environment.

Standard 10: Clinical Standards for Prescribing Methadone Maintenance Therapy

Nurse Practitioners with an exemption from Health Canada – Office of Controlled Substances, Methadone Program are responsible to prescribe Methadone Maintenance Therapy (MMT) for managing clients with opiate additions in a safe and effective manner.

10.1 Complete the Centre for Addictions and Mental Health (CAMH) Opioid Dependence Treatment Core Course for opioid dependency (or equivalent course at the discretion of the CRNNS) prior to applying for a methadone exemption.

10.2 Complete the minimum equivalent of one day of clinical training with a physician who holds an exemption for Methadone Maintenance Therapy.

10.3 Obtain and maintain an exemption for Methadone Maintenance Therapy for opioid dependency from Health Canada Office of Controlled Substances, Methadone Program and issued by the CRNNS.

10.4 Prescribe Methadone Maintenance Therapy, when indicated, according to evidence and guidelines contained in the current version of the College of Physicians and Surgeons of Nova Scotia (CPSNS) Methadone Maintenance Treatment Handbook.

Standard 11: Clinical Standards for Prescribing Methadone for Management of Chronic Non-Cancer Pain

Nurse Practitioner with an exemption under Section 56 of the Controlled Drugs and Substances Act are responsible to prescribe methadone for managing clients with chronic non-cancer pain in a safe and effective manner.

11.1 Review the most current guidelines for utilizing methadone for management of chronic non-cancer pain and reflect on implications for focus of practice.

11.2 Complete the minimum equivalent of one day of clinical training with a physician who holds an exemption and experience in Methadone use for pain management.

11.3 Obtain and maintain an exemption license for Methadone for analgesia from Health Canada Office of Controlled Substances, Methadone Program and issued by the CRNNS.

11.4 Prescribe Methadone for chronic non-cancer pain, when indicated, according to current evidence and guidelines.

Code of Ethics for Registered Nurses

The Canadian Nurses Association’s Code of Ethics for Registered Nurses is the code that guides RNs and NPs in Nova Scotia. It has been developed by registered nurses for registered nurses and can assist nurses in practising ethically and working through ethical challenges that arise in their practice with individuals, families, communities and the health systems. It is intended for registered nurse in all contexts, practice settings and levels of decision-making.