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CRNNS Regulatory Policies (12 Competencies)

The NP Jurisprudence Examination uses a multiple choice format that consists of a variety of questions that have been developed to assess the applicant’s competencies within four (4) categories: Regulatory Policies, relevant Federal Legislation, relevant Provincial Legislation and relevant Provincial Policies. Within each of these categories is a list of policies &/or legislation to be tested. To guide your study, each section includes a list of competencies, objectives, a synopsis of information and links to relevant resources.  This study guide is specific to regulatory policies.


Nurse Practitioner Guidelines for Collaborative Practice (1 competency)

1. Practises in accordance with the Nurse Practitioner Guidelines for Collaborative Practice

Objectives

The nurse practitioner will:

  • describe the purpose of the having a collaborative practice relationship with a physician(s)
  • state the regulatory requirement to submit verification of an established collaborative practice relationship
  • identify the essential components to consider in the establishment of a collaborative practice team

SYNOPSIS OF INFORMATION

In order to practice in Nova Scotia, nurse practitioners are required by legislation (RN Act, 2006) to establish a collaborative practice relationship with a physician or group of physicians. This relationship ensures that nurse practitioners have access to at least one physician who has agreed to be available for client-care consultation (in person, by telephone, in writing or electronically). This formal collaborative relationship does not preclude the nurse practitioner from:

  • collaborating with other physicians or providing care to other physician’s patients;
  • collaborating with a physician(s) who are located at a different geographic location;
  • providing services when the collaborating physician is not available, provided an alternative physician is made available for consultation; and
  • providing care to clients who do not have a primary care physician.

CRNNS must receive the Nurse Practitioner Population & Setting Verification Form prior to the initiation of a collaborative practice and the provision of NP services. This process enables CRNNS to document the NP practice on the CRNNS website.  Medical Services Insurance (MSI) will not process the NP application for billing and prescriber numbers until this process is complete.

The RN Act (2006) and RN Regulations (2009) require nurse practitioners and employers to notify CRNNS when nurse practitioners are about to change their patient population or practice setting. CRNNS also requires nurse practitioners to notify CRNNS when:

  • Initiating a new collaborative practice relationship (CPR)
  • Adding a collaborative physician to an existing CPR
  • Removing a collaborative physician from an existing CPR
  • Changing client population
  • Changing practice setting
  • Leaving collaborative practice relationship
  • Add a site to an existing CPR

The Nurse Practitioner Guidelines for Collaborative Practice identify the following components as priorities when establishing a new collaborative practice:

  • Identify the client population
  • Determine the context of practice
  • Service delivery
  • Structures and processes
  • Linkages
  • Responsibilities and accountabilities of health team members

RESOURCES

Nurse Practitioner – Competence Assessment Program (1 competency)

1. Complies with CRNNS NP-competence assessment program policies

Objectives

The nurse practitioner will:

  • state the purpose of the CRNNS NP Competence Assessment Program
  • describe the potential outcomes of the NP Competence Assessment Program

SYNOPSIS OF INFORMATION

The Nurse Practitioner Committee is established by legislative authority to conduct competence assessments for nurse practitioners, or applicants for a nurse practitioner’s licence, where:

  • a NP has changed practice settings or is working with a different client population;
  • a NP has not maintained their 600 hours of practice in the 2 years immediately before his/her application for entry in the nurse practitioner roster;
  • an applicant’s NP program completed outside of Nova Scotia is not equivalent to a Nova Scotia NP Program;
  • documents cannot be obtained by an applicant for reasons beyond the applicant’s control;
  • a competence assessment is otherwise required by the Act or these regulations.

Depending on the nature of the application, the NP may be required to complete supervised clinical practicum hours and/or submit case studies. Depending on the change of client population and clinical setting, additional recommendations can be required by the NP Committee.  Completed documents submitted by the applicant are reviewed for evidence that 100% of the critical competencies and 80% of the very important competencies are met. Critical competencies are defined as those that must be demonstrated by the applicant or achieved prior to granting a nurse practitioner licence. Very Important competencies are those that should be possessed by the applicant.

Potential outcomes of the NP Competency Assessment Program include:

  • there is no requirement for further NP education or supervised practice
  • a supervised clinical practicum followed by submission of relevant case studies for review by the NP Committee
  • remedial case studies if the NP is unsuccessful on the first case study submission and review
  • completion of specific NP university course work

RESOURCES

Nurse Practitioner – Quality Monitoring and Improvement Program (1 competency)

1. Complies with the Nurse Practitioner – Quality Monitoring and Improvement Program (NP-QMP)

Objectives

The nurse practitioner will:

  • state the purpose of the NP-QMP
  • state that the NP-QMP is a mandatory program to be completed once every 5 years
  • describe the requirement of the Primary Practice Review and the Secondary Practice Review
  • describe the potential outcomes of the secondary practice review

SYNOPSIS OF INFORMATION

The RN Act 2006 requires that the College of Registered Nurses of Nova Scotia establish a continuous quality and improvement program for nurse practitioners. NPs who have been in practice for a minimum of two years full-time or three years part-time must participate in this program once every five years.

The purpose of the NP-QMP™ is to:

  • be supportive in nature and assist nurse practitioners continuously improve their practice;
  • provide the opportunity for self-reflection through self-assessment
  • provide feedback from clients / patients / residents / parent / guardian on how their needs are being met
  • provide practice feedback from NP and medical colleagues, co-workers and other health professionals
  • provide recommendations for professional development activities, if deemed appropriate

In the primary review, the NP-QMP™ provides NPs with detailed, multi-source performance feedback from a comprehensive self-assessment, NP and physician colleagues, other health professionals and co-workers, and patients/residents and/or parents/guardians. This feedback is presented to NPs in a confidential report and provides the information they need to set goals to improve their practice.

The decision on whether a nurse practitioner must undergo a secondary practice review is made by the Interdisciplinary Nurse Practitioner Practice Review Committee (IDPRC). The purpose of a secondary practice review is to assist in the development of recommendations for an NP to improve her/his practice. Recommendations could include, but are not limited to, additional education or a change in practice procedures.

A secondary practice review is conducted by an NP practice reviewer who has a similar practice background to the NP under review. The NP practice reviewer is oriented to the secondary practice review process which includes a telephone interview, site visit, formal chart audit and chart‐ stimulated recall interview. Individual interviews may also be conducted with collaborating physician(s) and other colleagues.

The NP reviewer will prepare a report for the Interdisciplinary NP Practice Review Committee based on the results of the secondary practice review. The report is anonymous and does not identify the NP being reviewed.

If the NP practice reviewer observes evidence of unsafe practice during an on-site visit, including but not limited to, active substance use, gross incompetence with a high potential for client harm, and/or observation of abusive behavior to clients, the practice review will be terminated. The NP reviewer will inform the NP and CRNNS that the review is being terminated and a complaint may be submitted to CRNNS.

In the event that:

    1. the NP has not cooperated with the review;
    2. the NP does not comply with the requirements for remediation set by the IDPRC; or
    3. the IDPRC has reasonable grounds to believe that the NP poses a risk to the public that cannot be addressed within the NP-QMP™,

the IDPRC may disclose to the employer and must disclose to the CRNNS CEO/Registrar such information (including any written and electronic documentation), including the results of any competence assessment and bridging education, as is necessary to permit the employer and the CEO/Registrar to take appropriate action.

RESOURCES

Scope of Practice (4 competencies)

1. Practises within a collaborative practice model

Objectives

The nurse practitioner will:

  • define collaborative practice

2. Practises within scope of practice when making and communicating a diagnosis

 Objectives

The nurse practitioner will:

  • state that NPs are authorized to communicate a diagnosis to clients and other health professionals

3. Practices within scope of practice when managing client care.

Objectives:

The nurse practitioner will:

  • use best evidence and consider potential therapeutic benefit and risk when prescribing pharmacological and non-pharmacological therapies, including controlled drugs and substances.
  • perform non-invasive and invasive interventions for which they have developed and maintained competence.
  • use available drug information systems to verify history of clients’ medications.

4. Practises within scope of practice for consultation and referral

 Objectives

The nurse practitioner will be able to:

  • describe the difference between consultation and referral
  • describe when consultation or referral is required in the management of a client health condition
  • identify that NPs can refer clients to other health providers, including specialist physicians
  • identify that NPs can accept referrals and consultation from other health providers

SYNOPSIS OF INFORMATION

The practice of a nurse practitioner is defined as the application of advanced nursing knowledge, skills and judgment in addition to the practice of nursing in which a nurse practitioner in collaborative practice may, in accordance with standards for nurse practitioners, do one or more of the following:

  • make a diagnosis identifying a disease, disorder or condition,
  • communicate the diagnosis to the client and health care professionals as appropriate,
  • perform procedures,
  • initiate, order or prescribe consultations, referrals and other acts,
  • order and interpret screening and diagnostic tests, and recommend, prescribe or reorder drugs, blood, blood products and related paraphernalia,

and also includes research, education, consultation, management, administration, regulation, policy or system development.

Collaborative practice is defined as a relationship among a nurse practitioner, a physician or group of physicians, an employing organization and other health professionals who are relevant to the nurse practitioner’s practice, that enables the health-care providers in this relationship to work together to use their separate and shared knowledge and skills to provide optimum client-centered care in accordance with standards of practice for nurse practitioners and the guidelines for collaborative practice teams and employers of nurse practitioners approved by the College.

Prescriptive Authority

NPs have the authority to prescribe pharmaceuticals listed in or approved for Schedule F of the Food and Drugs Act (Canada) and/or pharmaceuticals listed in Schedule I of the NAPRA (provincial) Schedules, including pharmaceuticals under the Controlled Drugs and Substances Act (CDSA). Non-prescription pharmaceuticals (NAPRA Schedule II and III) can be obtained without a prescription; however, NPs can write a prescription for such pharmaceuticals if required by clients for insurance coverage.

NPs use research evidence, clinical practice guidelines and best practice when prescribing and monitoring pharmacological therapies. When prescribing pharmaceuticals, NPs consider therapeutic benefits, potential risks, cost-effectiveness and provisions of public and private insurance plans. NPs evaluate clients’ responses to drug therapy and adjust treatments as necessary.

The Continued Care Prescriptions Agreement between the College of Registered Nurses of Nova Scotia and the Nova Scotia College of Pharmacists authorizes a pharmacist to provide a continued care prescription (CCP) to a patient where an urgent need for patient drug therapy management exists and the prescribing nurse practitioner is unavailable to provide refill authorization. This agreement enables patient to access continued care prescriptions and provides a mechanism for pharmacists to extend an existing prescription written by a nurse practitioner for up to 30 days. Under the Pharmacist Drug Prescribing Regulations, a pharmacist may prescribe a renewal of a prescription when certain standards are met.

Screening and Diagnostic Tests Authority

NPs have the authority to order and interpret laboratory and other screening and diagnostic tests in accordance with their educational preparation, competence and focus of practice. NPs order diagnostic imaging tests and act on radiologists’ interpretation. In specific practice areas, NPs may be required to interpret a diagnostic imaging test for which they have received specific education (e.g., endotracheal tube placement, simple fractures). NPs are responsible for any required follow-up.

All family physicians and NPs in Nova Scotia may order adult MRI services directly without prior approval from a specialist or radiologist. All requests for MRI services are screened by a local radiologist for appropriateness and triaged according to level of urgency.

Invasive and Non-Invasive Procedures Authority

NPs have the authority to perform both non-invasive and invasive procedures in accordance with their educational preparation, competence and focus of practice. NPs are responsible to obtain informed consent and for any required follow-up.

Consultation and Referral

Consultation is defined as a request for another health professional’s advice on the care of a client. The goal is to enhance patient care and/or improve the skills and confidence of the professional making the request (i.e. consultee). The consultant may or may not see the patient directly. The responsibility for clinical outcomes remains with the consultee, who is free to accept or reject the advice of the consultant.

Referral is defined as an explicit request for another health professional to become involved in the care of a client.  Patient care is enhanced by relinquishing care, or aspects of care, to another expert provider whose is perceived to be more essential to the patient’s care. The responsibility for clinical outcomes is negotiable between the referring provider and the accepting provider, but responsibility is often assumed (at least for aspects of care) by the professional accepting the referral.

In accordance with the Nurse Practitioner Standards of Practice (2018), NPs 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. NPs must 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. Prior to acting on advice from other health professionals, NPs are required to evaluate and discuss the recommendations with the client. In addition, NPs 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.

RESOURCES

Standards of Practice for Nurse Practitioners (1 competency)

1. Practises in accordance with the standards of practice for nurse practitioners as determined by CRNNS

 Objectives

The nurse practitioner will:

  • articulate the purpose of the standard of practice for nurse practitioners
  • use the standards of practice for nurse practitioners to guide their practice in relation to NP:
    • responsibility and accountability
    • leadership and advocacy
    • assessment and diagnosis
    • client care management
    • collaboration, consultation and referral

SYNOPSIS OF INFORMATION

The College of Registered Nurses of Nova Scotia (CRNNS) sets the practice standards for registered nurses and nurse practitioners to support the delivery of safe, competent, compassionate and ethical care. Nurse practitioners care for various client populations in a variety of practice settings.

The Nurse Practitioner Standards of Practice (2018) outlines the professional and legal obligations and accountabilities of nurse practitioners and provides a common understanding of nurse practitioner practice expectations in Nova Scotia. The standards also identify the performance levels that nurse practitioners are required to achieve in practice.

This document is a complement to the Entry-Level Competencies for Nurse Practitioners in Canada (2016). Competencies are the specific knowledge, skills, abilities and judgment required for a nurse practitioner to practise safely and ethically with a designated client population in a specific role and practice setting.

It is important to note that NPs must 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.

As part of their comprehensive assessment of the client’s diagnoses, NPs are required to use available drug information systems to verify history of clients’ prescribed medications, including controlled drugs and substances, when initiating, changing or discontinuing medications.

If an NP changes practice location, they must inform NSPMP to arrange for necessary changes to their duplicate prescription pad.

RESOURCES

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