1. College of Registered Nurses of Manitoba Registered Nurse Extended Practice Orientation

2. Welcome! Welcome to the orientation for the Registered Nurse Extended Practice Register. This presentation is intended for members who are newly registered as an RN(EP). This presentation contains information current as of January 2007.

3. Overview The Extended Practice Regulation Standards of Practice for Registered Nurses on the Extended Practice Register Competencies for the Registered Nurse (Extended Practice) RN(EP) Register Continuing Competence for the RN(EP) Questions

4. The Extended Practice Regulation

5. As well as defining the requirements for registration on the RN(EP) register, the regulation sets requirements for RN(EP) practice, the Advisory Committee and the included practices.regulation The Extended Practice Regulation

6. The RN(EP) may order and receive reports of screening and diagnostic tests specified in Schedule A of the Regulation.Schedule A of the Regulation Other screening and diagnostic tests may be ordered under 5(2): a.The nurse is an employee of a regional health authority or health care facility and is permitted to order the tests by a written policy of the facility; or b.The test is required to monitor a patient’s chronic illness or injury and the nurse has consulted with the patient’s physician whose name appears on the test requisition. The Extended Practice Regulation: Ordering Tests

7. Section 6 of the Regulation sets out the prescribing authority of the RN(EP), subject to the restrictions of the Controlled Drugs and Substances Act.Controlled Drugs and Substances Act –6(1)(a): Prescribe any drug or device referred to in Schedule B (“Any drug or device listed in Part 1 or 2 of the Specified Drugs Regulation under The Prescription Drugs Cost Assistance Act”) and distribute samples of them;Specified Drugs RegulationThe Prescription Drugs Cost Assistance Act –6(1)(b): Prescribe drugs or devices other than those in Schedule B if the nurse is an employee of a regional health authority or health care facility and is permitted to order the tests by a written policy of the facility; or The Extended Practice Regulation: Prescribing Drugs

8. –6(1)(c): Prescribe any non-prescription drug in order to permit the patient to access a drug plan that covers non-prescription drugs. –6(2): may renew prescriptions for drugs in addition to those in (1)(a) only for patients who are being managed collaboratively with another health care provided with authority to prescribe the drug. The Extended Practice Regulation: Prescribing Drugs (continued)

9. Section 7 addresses the prescribing of vaccines: –7(a): A vaccine listed in the Specified Drugs RegulationSpecified Drugs Regulation –7(b): A vaccine not listed in the Specified Drugs Regulation that may be dispensed through a retail pharmacy;Specified Drugs Regulation –7(c): A vaccine or biologic used in a provincial immunization program when required to be prescribed for a person who did not meet the provincial criteria for free vaccine. –7(d): BCG vaccine and rabies vaccine. The Extended Practice Regulation: Prescribing Vaccines

10. Section 8 sets out the authority regarding minor surgical and invasive procedures: –8(a): Suturing, but not below the fascia or in a case where there might be an underlying injury; The Extended Practice Regulation: Performing Minor Surgical and Invasive Procedures

11. –8(b): Any of the following procedures when required for the purpose of treating, assessing or diagnosing a person or assisting them with health management: (i) A procedure that requires putting an instrument beyond the point in the nasal passages where they normally narrow, beyond the uvula, beyond the opening of the urethra, or below the dermis or below a mucous membrane. (ii) A procedure that requires putting an instrument or finder beyond the anal verge, or into a an artificial opening into the body, (iii) A procedure that requires putting an instrument or finger beyond the labia majora, (iv) Creating an opening into the body that requires putting an instrument into the body. The Extended Practice Regulation: Performing Minor Surgical and Invasive Procedures

12. Authority for the practice is described in the Extended Practice RegulationExtended Practice Regulation Important additional information: –Specified Drugs RegulationSpecified Drugs Regulation –The Prescription Drugs Cost Assistance ActThe Prescription Drugs Cost Assistance Act –The Standards of Practice for the Registered Nurse on the Extended Practice RegisterThe Standards of Practice for the Registered Nurse on the Extended Practice Register –Controlled Drugs and Substances ActControlled Drugs and Substances Act The Extended Practice Regulation: Summary Regarding Included Practice

13. Standards of Practice for Registered Nurses on the Extended Practice Register

14. In addition to upholding the Standards of Practice for Registered Nurses in Manitoba and the Code of Ethics for Registered Nurses, RN(EP)s are expected to meet the Standards of Practice for Registered Nurses on the Extended Practice Register.Standards of Practice for Registered Nurses in ManitobaCode of Ethics for Registered NursesStandards of Practice for Registered Nurses on the Extended Practice Register Standards of Practice for RN(EP)

15. RN(EP) Nursing Practice Expectations Nursing Practice Expectations represent achievable levels of performance approved by the College of Registered Nurses of Manitoba Board of Directors.Board of Directors

16. These standards set nursing practice expectations for the RN(EP) with regards to Consultation and Collaboration, Prescribing Drugs, Ordering Screening and Diagnostic Tests, and Performing Minor Surgical and Invasive Procedures. In addition, expectations regarding the monitoring of adverse drug reactions are outlined in Appendix A of these Standards. Standards of Practice for RN(EP)

17. RN(EP)s consult and collaborate with other health professionals as appropriate and in accordance with the Competencies for the Registered Nurse (Extended Practice) Register, to ensure that the overall health care needs of their clients are met.Competencies for the Registered Nurse (Extended Practice) Register Standards of Practice for RN(EP): Standard 1: Consultation and Collaboration

18. The cornerstone of multidisciplinary care, involves working with one or members of the health care team who each make a unique contribution from within the limits of his or her scope of practice. Standards of Practice for RN(EP): Collaboration

19. Consultation is an explicit request by an RN(EP) for another health care professional to become involved in the care of a client for which the RN(EP) has primary responsibility. Consultation can occur in a variety of ways including face to face discussion, by telephone and in writing. Standards of Practice for RN(EP): Consultation

20. Consultation takes place when the registered nurse reaches the limit of the RN(EP) scope of practice, beyond which she/he cannot provide care independently and additional information and/or assistance is required from a professional with a more extensive knowledge base related to the specific client situation. Standards of Practice for RN(EP): Consultation (continued)

21. There are 7 indicators for Standard I. They reflect requirements to establish consultative relationships, to consult when appropriate, to be clear about consultation expectations, to be timely, to make joint decisions about transfer of care, and to establish structures, processes and communication process for effective consultation. Standards of Practice for RN(EP): Standard 1: Consultation and Collaboration

22. An inter-professional process for communication and decision making that enables the separate and shared knowledge and skills of care providers to synergistically influence the client/patient care provided. Way, D. Jones, Bushing, N. (2000). Implementation Strategies: Collaboration in Primary Care--Family Doctors and Nursing Practitioners Delivering Shared Care. Ontario College of Family Physicians. Standards of Practice for RN(EP): Collaborative Practice

23. RN(EP)s prescribe drugs relevant to the nurse’s area of practice and client population served in accordance with the Extended Practice Regulation, all other relevant provincial and federal legislation, the Competencies for the Registered Nurse (Extended Practice) RN(EP) Register and recognized best practices.Extended Practice RegulationCompetencies for the Registered Nurse (Extended Practice) RN(EP) Register Standards of Practice for RN(EP): Standard II: Prescribing Drugs

24. There are 11 indicators (indicators 8-18) for Standard II. Indicators 8, 15 and 16 are explicit regarding what must be recorded on a prescription or faxed prescription. These requirements reflect best practices in safe prescribing. Indicators 10 and 14 require that prescriptions are based on direct client contact, relevant to the nurse’s area of practice and client population served, and may not include the RN(EP) family members or themselves. Standards of Practice for RN(EP): Standard II: Prescribing Drugs (continued)

25. Security of prescriptions and blank prescriptions are addressed in indicators 13, 15, and 16. Record keeping, monitoring the response to therapy and consultation requirements are in indicators 11, 12 and 18. Indicator 17 requires the monitoring of adverse drug reactions in accordance with Health Canada requirements (Appendix A).adverse drug reactions Standards of Practice for RN(EP): Standard II: Prescribing Drugs (continued)

26. The definition of a serious adverse drug reaction (ADR) is given in Appendix A. For a copy of the ADR reporting form, and assistance in completing the forms, visit the Health Canada Website, Canadian Adverse Drug Reaction Monitoring Program.Health Canada Website Standards of Practice for RN(EP): Monitoring Adverse Drug Reactions

27. In addition to the Adverse Drug Reaction Monitoring Program, Health Canada provides support to monitoring vaccine-associated adverse events. Download a copy of the form from the Health Canada website.Health Canada website Further information is available on the Health Canada website.Health Canada website Standards of Practice for RN(EP): Report of a Vaccine – Associated Adverse Event

28. RN(EP)s order specific screening and diagnostic tests relevant to the nurse’s area of practice and client population served in accordance with the Extended Practice Regulation, the Laboratory Requisition Regulation of the Health Services Insurance Act, the Competencies for the RN(EP) Register and recognized best practices. Extended Practice RegulationLaboratory Requisition RegulationCompetencies for the RN(EP) Register Standards of Practice for RN(EP): Standard III: Ordering Screening and Diagnostic Tests

29. There are 6 indicators for Standard III (indicators 19- 24). Indicator 19 describes the circumstances for which the RN(EP) can order a test—e.g., for episodic illness, to monitor condition, for screening purposes. Indicator 20 requires the development of processes to track the results and ensure communication with other health professionals in a timely way. Standards of Practice for RN(EP): Standard III: Ordering Screening and Diagnostic Tests

30. Indicator 21 requires best practice evidence to be used regarding the appropriateness, contraindications, safety and cost effectiveness. Indicators 22 - 24 addresses the requirement to adequately inform the client about the test, to adhere to standards for ordering, documenting and reporting results and requirements for understanding test results and interpretations. Standards of Practice for RN(EP): Standard III: Ordering Screening and Diagnostic Tests

31. Resources related to Required Reporting of Diagnostic Test Results –Manitoba Health, Public Health Branch, Communicable Disease Control unit: Communicable Disease Management Protocol Manual available at www.gov.mb.ca/health/publichealth/cdc/protocol/index.htmlwww.gov.mb.ca/health/publichealth/cdc/protocol/index.html List: Diseases Reportable by Health Professionals and LaboratoriesDiseases Reportable by Health Professionals and Laboratories –All new cases of first diagnosis of malignant neoplasm, as well as each new primary cancer, are reported to the Central Cancer Registry, Cancer Care Manitoba, 675 McDermot Ave, Winnipeg MB R3E 0V9 or visit the website: cancercare.mb.cacancercare.mb.ca Standards of Practice for RN(EP): Standard III: Ordering Screening and Diagnostic Tests

32. RN(EP)s perform minor surgical and invasive procedures competently and in accordance with the Extended Practice Regulation, Competencies for the Registered Nurse (Extended Practice) RN(EP) Register and recognized best practice. Extended Practice RegulationCompetencies for the Registered Nurse (Extended Practice) RN(EP) Register There are 4 indicators (indicators 25-28) for Standard IV. Standards of Practice for RN(EP): Standard IV: Performing Minor Surgical and Invasive Procedures

33. Indicators 25 and 26 address the requirement to only perform those procedures for which the RN(EP) is competent, and the need to develop and maintain competence. Indicators 27 and 28 require that these procedures are only done with written request and as required for the assessment, treatment or management of an individual’s health. Standards of Practice for RN(EP): Standard IV: Performing Minor Surgical and Invasive Procedures

34. See the Extended Practice Regulation section 8.Extended Practice Regulation Standards of Practice for RN(EP): Standard IV Resource

35. Summary Regarding the Standards of Practice for RN(EP) Members on the RN(EP) register are expected to comply with these Standards, the Standards of Practice for Registered Nurses, and the Code of Ethics for Registered Nurses.StandardsStandards of Practice for Registered NursesCode of Ethics for Registered Nurses Important additional resources include: –Extended Practice RegulationExtended Practice Regulation –Competencies for the Registered Nurse (Extended Practice) RN(EP) RegisterCompetencies for the Registered Nurse (Extended Practice) RN(EP) Register –List: Diseases Reportable by Health Professionals and LaboratoriesDiseases Reportable by Health Professionals and Laboratories

36. Competencies for the Registered Nurse (Extended Practice) RN(EP) Register

37. Competencies for the RN(EP) Register Registration on the RN(EP) register is based on the demonstration of competence at an advanced level in each of the four competency areas: 1.Assessment and Diagnosis of Client Health/Illness Status 2.Pharmacotherapeutics and other Therapeutic Interventions in Client Care Management 3.Population Health and Illness/Injury Prevention 4.Professional Responsibilities and Accountabilities

38. The first 4 indicators for this competency address everything from comprehensive health assessment, selecting diagnostic and screening tests, to diagnostic reasoning and diagnosis. Indicators 5 – 7 address essential communications with the client, other health care providers and written documentation expectations. Competencies for the RN(EP) Register Assessment and Diagnosis of Client Health/Illness Status

39. The 8 indicators in this area outline the required competencies for collaboration with the client, the knowledge base required for prescribing and consultation/collaboration expectations. In addition, these indicators set expectations for assessment, minor surgical and invasive procedures and interactions with a variety of health care providers. Competencies for the RN(EP) Register Pharmacotherapeutics and other Therapeutic Interventions

40. The seven indicators reflect advanced nursing practice in this competency, such as: –Collaboration with populations/communities and others –Initiation of health promotion/prevention programs –Developing follow-up systems for populations –Advocacy in relation to health policy Competencies for the RN(EP) Register Population Health and Illness/Injury Prevention

41. The RN(EP) must understand how the scope of practice of the RN(EP): –Affects their responsibilities and accountabilities; –Professional and legal standards; –Ethical decision making involved in the diagnosis and treatment of acute and chronic illness, including prescribing and administering medications; Competencies for the RN(EP) Register Professional Responsibilities and Accountabilities

42. –The RN(EP) must understand their own scope of practice and competence: the specific area(s) of practice and the client population for whom she/he is competent to provide services and provides only those services she/he is authorized and competent to provide; –Takes accountability for initiating referrals; –Practices in accordance with legislative acts, regulations, CRNM bylaws and Board of Director policies relevant to their area of practice and client population. CRNM bylaws Competencies for the RN(EP) Register Professional Responsibilities and Accountabilities

43. Continuing Competence Requirements for the RN(EP)

44. In accordance with Board policy, continuing competence requirements for RN(EP)s include: –I) Completion of a self-assessment based on the Standards of Practice for Registered Nurses on the Extended Practice Register and the Competencies for the Registered Nurse (Extended Practice) RN(EP) Register and a self development plan based on the self-assessment;Standards of Practice for Registered Nurses on the Extended Practice RegisterCompetencies for the Registered Nurse (Extended Practice) RN(EP) Register –II) Participation in annual peer case reviews; –III) Participation in quality of care evaluations; and –IV) 1,800 practice hours in the three-year period prior to the year for which registration renewal on the extended practice register is being sought or 600 hours in the previous year in an extended practice role Continuing Competence

45. RN(EP) Continuing Competence documents can be downloaded from the CRNM website.CRNM website Continuing Competence

46. Liability Protection

47. The Canadian Nurses Protective Society web address is www.cnps.ca. To enter the members only site, enter the user name “CRNM” and the password “assist”.www.cnps.ca Useful resources on this site include the CNPS/CNPA Joint Statement Regarding Liability Protection for Nurse Practitioners, a Nurse Practitioner section (username: crnm, password: assist), and information about what to do when things go wrong. CNPS/CNPA Joint Statement Regarding Liability Protection for Nurse PractitionersNurse Practitioner section

48. Liability Protection Information about CNPS and CNPS Plus is available from the CNPS website or by calling (800) 267-3390.CNPS website

49. Questions?

50. Questions You can access any of the CRNM Nursing Practice Consultants by phone or fax for assistance with your practice questions. Contact information is available on the Web.Contact information is available on the Web

51. College of Registered Nurses of Manitoba Registered Nurse Extended Practice Orientation