RNs seek broader prescribing powers in quest for more autonomy

CMAJ 2000;163(5):600-1

Specially educated nurses in parts of 3 provinces are already authorized to prescribe certain drugs; meanwhile, RNs in remote parts of Canada have been prescribing for years but the practice is situational and standards are inconsistent.

The CNA says new regulations would provide that consistency. They would also allow physicians to know what their nursing colleagues are qualified to do and reduce the need to delegate prescriptive authority, which can carry legal risks.

In Alberta, Newfoundland and Ontario, extended-practice nurses have already received authority from their provincial regulatory body to diagnose, manage illness and prescribe in certain circumstances. Ontario's 400 RN(EC)s [extended class] have been performing these duties since February 1998 and are allowed to prescribe some antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), contraceptives and other drugs. These nurses have a degree in nursing, a minimum of 2 years' primary care experience and have completed a 13-month postgraduate program.

On the east coast, Newfoundland's 24 nurse practitioners prescribe a range of medications, including anti-infective drugs, hormones and NSAIDs. They also have prescriptive authority during emergency situations such as acute asthma attacks. These nurses are responsible for knowing when a case is beyond their scope; they then consult a physician.

"Nurses don't want to be doctors," says Debbie Phillipchuk, a practice consultant with the Alberta Association of Registered Nurses (AARN). "Nurses want to prescribe within the roles they have." Alberta's extended class of RNs, who work exclusively in Northern and remote settings, prescribe many drugs. Now AARN is trying to give limited prescriptive powers to RN(EC)s in more populous areas, through the province's new Health Professions Act.

The association wants nurses to be able to prescribe certain drugs in certain practice situations. For example, an RN(EC) in a long-term-care setting might adjust palliative care medications or treat urinary tract infections or other common disorders within that population. These nurses would have to advise a physician of their actions. "RNs take very seriously the responsibility of prescribing and they feel there must be real restrictions on when and why," says Phillipchuk.

Alberta recently put another model to the test in Elnora, a town of 250 people 100 km northeast of Calgary, which has no doctor. This past year a nurse practitioner worked independently in the town in an extended role that included making some diagnoses and writing some prescriptions. She consulted with 2 physicians in neighbouring Trochu. The project was approved by both the Alberta Medical Association (AMA) and the provincial pharmacists' association.

"Sure physicians will feel threatened," says AMA CEO Dr. Bob Burns, "but we aren't going to be paternalistic about this or view it in terms of turf." The AMA wants to ensure that any professional group that has prescribing authority has demonstrated "robust" knowledge, has training standards and is self-regulating. Burns says the AMA's deepest concern surrounds the complexity and interactivity of pharmaceuticals. "The training must be quite extensive," he says.

The CNA concurs. Its brief to Health Canada's Office of Controlled Substances details the knowledge RNs would need to prescribe: training in pharmacology, pharmacotherapeutics, writing prescriptions, teaching and more. The brief also maintains that nurses have adequate systems in place to support expanded prescriptive authority and specifies which controlled drugs RNs should be authorized to prescribe.

The Office of Controlled Substances, which monitors drugs such as narcotics and barbiturates, is preparing regulations for its new Controlled Drugs and Substances Act (formerly the Narcotics Control Act). Currently, the office is looking at which professionals, in addition to physicians, dentists and veterinarians, should be authorized to prescribe these drugs.

But even if the federal government decides to give the nurses the right to prescribe controlled drugs, it's still up to each province and individual nursing regulatory body to decide whether to give the RNs more prescriptive authority.

The CNA brief argues that expanded authority would improve access to primary health care, allow for more flexible service delivery, legitimize current practices and help control spending.

Similar moves are already under way outside Canada. American nurse practitioners have limited authority to prescribe, and nurses in 11 states can prescribe controlled drugs. They report that their involvement reduces physicians' workload and saves them time. Meanwhile, England is implementing prescribing rights for all district nurses, health visitors and practice nurses by mid-2001. Other countries, including Iceland and New Zealand, are in the process of developing legislation.

"The health care system has to change," says MacDonald-Rencz. "The bottom line is that health care workers must work in a way that is responsive and in the best interest of the public." — Barbara Sibbald, CMAJ

© 2000 Canadian Medical Association or its licensors