This section is intended to support NPs in their understanding and application of the Nurse Practitioner practice standard.

NP practice is conducted within the context of the therapeutic nurse-client relationship. As always, NPs continue to provide health services (e.g., prescribe medication, perform procedures, etc) in accordance with the legal scope of NP practice, College standards and based on the following factors:

• clients' needs and circumstances
• individual NP competencies
• the practice setting.

For a complete description of the expectations for public protection that apply to NP practice, please see the Nurse Practitioner practice standard.

General

1. I just received my NP Certificate of Registration. How do I sign my name?

You must sign as either Nurse Practitioner (NP) or Registered Nurse, Extended Class [RN(EC)]. You may also add your specialty certificate designation:

• NP-Adult
• NP-Paediatrics
• NP-Primary Health Care (NP-PHC)

No other variations of the NP title may be used.

2. I am an NP-Adult. Can I provide health care services to children?

You are accountable for practising according to your specialty. As an NP registered in the adult specialty, it is expected that your clients will be adults. Should you occasionally be asked to provide health care services to a paediatric client, you must exercise judgment. Are you capable of providing the service? Can you manage the outcomes of the requested intervention? Do you have the appropriate resources available? Is it in the client’s best interest that you provide the service? If not, you may decide to refer the client to another health care provider, such as another NP or a physician.

Providing services to a client outside of the population you typically serve should be the exception, not the rule. If you occasionally provide health care services to paediatric clients, then you should inform the client or parent/guardian that you are an NP-Adult. Doing so promotes transparency.

3. I am an NP working in a hospital. Can I practise without medical directives?

Yes, NPs are permitted to diagnose, treat and prescribe treatment for hospital patients. Therefore, you can practise within the legal scope of NP practice without directives. However, if your clients require procedures that are not within the legal scope of NP practice (e.g., diagnostic tests not included on the Diagnostic Test List), then you will require an authorizing mechanism, such as a medical directive.

4. I work as an NP in a hospital. My employer requires me to use medical directives for procedures that are within the legal scope of NP practice. Is this appropriate?

While hospitals may choose to put parameters on NP practice, it is not accurate to refer to these parameters as "medical directives." Medical directives are orders for client care. As of July 1, 2011, NPs providing services to clients in hospital no longer required orders for procedures that they are legally authorized to perform under the Nursing Act, 1991.

Employers who choose to put parameters on NP practice may develop policies or agreements to describe the types of procedures that NPs perform. These policies should be developed in collaboration with NPs and reflect the best interests of clients. For further information about medical directives, please see Authorizing Mechanisms.

Ordering / performing tests

5. Am I restricted to ordering laboratory tests from a list?

No. Regulations under the Laboratory and Specimen Collection Centre Licensing Act no longer require laboratory tests ordered by NPs to be listed in regulation. This means that you are authorized to order laboratory tests, as appropriate, for your clients. The practice expectations for public protection when ordering laboratory tests are described in the Nurse Practitioner practice standard.

6. Am I restricted to ordering diagnostic tests from a list?

Yes. NPs are only authorized to order certain diagnostic tests permitted by legislation. To see what is authorized, review the Diagnostic Test List. The practice expectations for public protection when ordering diagnostic tests are described in the Nurse Practitioner practice standard. The College has recommended to government that this legislation be changed. For more information, see Bill 179 FAQ.

7. NPs are authorized to order prostate-specific antigen (PSA) laboratory tests for the purposes of diagnosing and monitoring clients. Can I also order PSA tests for screening purposes?

Yes. Although PSA screening for asymptomatic men is not recommended, clients sometimes request the tests and NPs can order them. In all cases, you should educate your clients about the criteria for PSA testing and the potential risks (e.g., inaccurate test results).

You should also inform clients that OHIP will pay for PSA testing only for diagnosing clients whose clinical history suggests they are at risk, or for monitoring clients who have been diagnosed with prostate cancer. You should advise clients who are not eligible for OHIP coverage to check their third-party insurance provider’s policies for coverage requirements. OHIP eligibility criteria for PSA testing are available here.

8. Can I perform point of care testing, such as rapid strep tests and urine dipstick analyses?

No. Health care professionals who perform laboratory tests for the purpose of diagnosing and treating their clients require an exemption under the Laboratory and Specimen Collection Centre Licensing Act. NPs are not exempt under this legislation. Therefore, you may perform point of care laboratory tests only with proper authorizing mechanisms (for example, a medical directive).

The College has recommended to government that this legislation be changed to exempt NPs and enable them to perform point of care laboratory tests, which are an essential part of NP practice. For more information, see Bill 179 FAQ.

9. I write orders for clients on discharge from hospital, such as requisitions for laboratory and diagnostic tests. What is my accountability in following up with clients in this situation?

As the health professional who ordered the test, you are also accountable for following up, or ensuring there is a reliable system in place for appropriate follow-up. This means that you, or the hospital, should have a system in place for reviewing the tests you have ordered and following up with clients when significant results are received. The nature of the follow-up will vary depending on the situation. For example, clients may be referred to the primary health care (PHC) provider for ongoing care, or a hospital outpatient clinic. You are required to document that you have informed clients of results and the directions for follow-up that you provided.

Safe transfer of accountability is facilitated by a timely discharge summary, including information about tests that have been ordered. To promote continuity of care, you can include a specific request on laboratory and diagnostic requisitions to have test results sent to both the hospital and the PHC provider.

You are accountable for communicating with clients the clinical significance of the tests being ordered, timelines for when they should undergo the test, potential implications of not undergoing the test, what type of follow-up to expect, and the process for communicating results to the client. You may want to provide a copy of the discharge summary to clients, which facilitates safe transfer of accountability. These discussions with clients should be documented.

10. What is my accountability if a client does not undergo a test that I have ordered?

There is a shared accountability; ultimately, clients make their own decision about whether to undergo a test. You are accountable for ensuring clients have the necessary information to make an informed decision about taking the test. In addition, you are expected to ensure systems are in place to track that you have ordered the test. This enables you to follow up with the client if required. If you learn that your client has not taken the test, it provides you with an opportunity to explore the client’s reasons and engage in additional health teaching. You should document your follow up with the client, including any unsuccessful follow-up attempts if the client does not respond.

11. Can I apply ultrasound?

You cannot apply “diagnostic ultrasound”, which is a controlled act. The forms of energy that NPs are authorized to apply must be specified in regulation, which has not yet been drafted by the government. Until the necessary regulations are in place, you must continue to use delegation for applying forms of energy, such as diagnostic ultrasound.

The use of “procedural ultrasound”, which is not used to make a diagnosis, is not a controlled act. Therefore, you may use ultrasound to perform procedures, such as paracentesis or placement of a peripherally inserted central catheter. The practice expectations for public protection when performing procedures are described in the Nurse Practitioner practice standard.

Prescribing / administering medication

12. Now that the NP drug list has been revoked, can I prescribe any medication?

You can prescribe most medications if appropriate for your client but you cannot prescribe controlled substances (e.g., opiates, benzodiazepines) until provincial regulations are amended to enable this practice. A controlled substance is one that is included in Schedule I, II, III, IV or V of the Controlled Drugs and Substances Act. (See questions 21-29 for more information.)

In addition, under the Health Insurance Act regulation, certain medications that may be provided by hospitals to outpatients for use at home are only covered by the Ontario Health Insurance Plan when they are prescribed by a physician for a specific indication (e.g., pentamidine or zidovudine prescribed for a client with HIV). A complete overview of these medications is available here. While it is within the legal scope of NP practice to prescribe these medications to clients in these circumstances, the medication will not be insured by the Ontario government until the regulation is amended.

You are expected to continue to prescribe based on the client’s need, your individual competencies and the practice setting. The practice expectations for public protection when prescribing are described in the Nurse Practitioner practice standard.

13. Can I prescribe Tramadol?

Yes. An NP can prescribe Tramadol. The drug is an opiate analgesic but it is not a controlled substance under the Controlled Drugs and Substances Act.

At some point in the future, Health Canada may classify Tramadol as a controlled substance. If this happens, NPs will no longer be able to prescribe this medication. NPs are accountable for knowing the legislation that affects their practice and complying accordingly.

The College will update its website if this change occurs.

14. What are the requirements when prescribing Tramadol?

Tramadol is a monitored drug under the Ontario government’s Narcotics Safety and Awareness Act, 2010. NPs and other health professionals who prescribe or dispense monitored drugs must know and comply with specific legal requirements. For example, NPs must include a client identification number from a government-approved form of identification (e.g., Ontario Health Card) on the prescription for Tramadol. For more information about the legislative requirements, including a list of the acceptable forms of identification, visit the Ministry of Health and Long-Term Care’s website.

Like other opiates, Tramadol is subject to potential misuse and abuse. NPs are expected to consider this in their clinical decision-making to ensure safe prescribing. For example, NPs should assess clients for potential drug abuse behaviour and document their findings. Health Canada’s Guide for Health Professionals: Abuse and Diversion of Controlled Substances provides useful guidance.

As always, NPs must apply the practice expectations for public protection described in the Nurse Practitioner practice standard.

15. Now that there is no NP drug list, can I complete a request under the Ontario Drug Benefit Exceptional Access Program?

No. For further information, see the section entitled Exceptional Access Program in NP Practice Resources.

16. Can I authorize a directive for another nurse to administer a medication?

Yes, you may write a directive for a medication to be provided to clients who meet specific conditions and when specific circumstances exist. The directive is your order for the medication. The other health professional is implementing the order. In this situation, you are accountable for the order (i.e., the directive) and the other nurse is accountable for implementing the directive appropriately (i.e., proper assessment to ensure the client meets the conditions, not using the directive if discrepancies exist, consulting the prescriber when required, proper medication administration, etc.).

To be sound, directives must have the same integrity as a direct client order (e.g., medication name, dose, route of administration, etc.). When developing and implementing directives, you are expected to apply the expectations for public protection set out in the College’s practice documents. For further information, see Authorizing Mechanisms and Directives.

17. The Nurse Practitioner practice standard says that NPs can order blood products; however, my employer indicates that this is against “standards.” What does this mean?

Ordering blood or blood products is within the legal scope of NP practice. However, your employer may have adopted a policy that restricts this authority. For example, hospitals may adopt the Canadian Standards Association standards related to the collection, processing, storage and use of human blood and blood components for transfusion, which indicate that blood transfusions must be authorized by physicians.

If this procedure is appropriate for your client population and practice setting, you may want to work with your employer to explore strategies to enable you to order blood or blood products. The practice expectations for public protection when ordering the administration of blood or blood products are described in the Nurse Practitioner practice standard.

18. Can I order oxygen?

Yes, ordering oxygen is within the legal scope of NP practice and you can order it if it is appropriate for your client population and practice setting. The practice expectations for public protection when ordering the administration of oxygen are described in the Nurse Practitioner Practice Standard.

19. How soon do I need to sign off on verbal and telephone orders?

You should check your employer’s policy regarding the sign-off on verbal and telephone orders as employers may have different requirements. In the event that your employer does not have a policy, you should advocate for one.

20. Why must I include my registration number on prescriptions?

College requires that your registration number be included on prescriptions for authenticity. An NP’s registration number is a unique identifier and the most direct way for a pharmacist to verify that the prescription was authorized by a legitimate prescriber and to make direct contact with the NP to validate the prescription. The registration number is also used by insurers, such as the Ontario Drug Benefit program and others, to verify prescriptions when reimbursing clients or pharmacists directly.

Controlled substances

21. What are controlled substances and why are they restricted?
A controlled substance is one that is included in Schedule I, II, III, IV or V of the federal Controlled Drugs and Substances Act. A wide variety of medications used in health care are controlled substances, including opiates, benzodiazepines, amphetamines, sedatives, anti-emetics and hormonal therapies, among others. Controlled substances are restricted because they present a high risk for potential abuse, misuse or diversion.

22. Can I prescribe controlled substances?
No, it is illegal for NPs to prescribe controlled substances in Ontario. In 2012, the federal government changed the Controlled Drugs and Substances Act to allow NPs to prescribe controlled substances; however, until the Ontario law (regulation 275/94 of the Nursing Act, 1991) is changed,  NPs in Ontario are prohibited from this practice. All nurses are accountable for knowing and complying with the laws that apply to their practice.

You may not always be aware that a medication you intend to prescribe is a controlled substance, so you must verify and if it is, refrain from prescribing it. Verify which medications are controlled substances by checking Schedule I, II, III, IV and V of the Controlled Drugs and Substances Act.

23. What is required to change the law to permit NPs to prescribe controlled substances in Ontario?
The College must propose changes to regulations under the Nursing Act and the Ontario government must approve amendments for the law to change.  Depending on the complexity of the regulation, it can take approximately two years for the College to develop a regulation for Council approval. Regulations approved by Council are subject to ministerial review, amendment and government approval. The College will inform members and stakeholders about developments though its website, The Standard and other appropriate channels.

24. Will NPs be required to complete specific education before they gain the legal authority to prescribe controlled substances?
The College is still in the early stages of exploring an educational requirement. At its March meeting, the College’s Council supported that NPs may be required to complete specific education before they are authorized to prescribe controlled substances.
The College will communicate details, such as approved courses if applicable, in the future.

25. Will this education eventually be included in entry-level education programs for NPs?
If the regulation authorizing NPs to prescribe controlled substances takes effect, entry-level NP education programs in Ontario will be expected to include education related to the competencies for safe, effective and ethical prescribing of controlled substances.

26. What do I do if I determine that a client requires a prescription for a controlled substance?
NPs can expect to encounter clients requiring prescriptions for controlled substances, since many medications are controlled substances.  You should plan for this anticipated client care need by establishing strategies consistent with College standards and guidelines. You should also work with your employer to ensure you have access to resources for meeting client needs. In this case, the resource you need is physician availability. If the client needs a prescription for a controlled substance, the prescription must be filled out by a physician in a manner that is consistent with the physician's regulatory obligations.  

27. Can I create a prescription for a controlled substance if a physician agrees and signs the prescription?
It is not acceptable to create a prescription that contains your contact information if another health professional signs the prescription. This includes prescriptions in written form (where the NP hand-writes the prescription, consults a physician and the physician signs the script) or in electronic form (where the NP uses the facility’s electronic medical record to generate the prescription, which is then printed and signed by the physician). The person who signs the prescription is considered the prescriber. Prescriptions are a form of communication about client care between a prescriber and a dispenser; therefore, they must be complete, accurate and clear. The prescription must include the prescriber's details (e.g., name, registration number) and contact information. "Mixing" your contact information with a physician’s signature causes confusion for pharmacists about who is prescribing the medication and creates the risk of error. For example, the pharmacist may enter your registration number along with the prescription into the provincial Narcotics Monitoring System (see question 29).

28. I am an NP with a clinical focus in pain management. Can I use a medical directive to provide opioid medications to clients?
No. Medical directives cannot be used to provide narcotics. Health Canada, the federal department responsible for administering the Controlled Drugs and Substances Act, does not allow medical directives to be used for controlled substances. To provide these drugs, you need a client-specific order that a physician has authorized. You will also need a physician’s order to change the dosage or renew a prescription.

29. There used to be two benzodiazepines (Lorazepam and Diazepam) on the NP drug list for emergency purposes. Now that there is no drug list, can I prescribe these drugs?
No. These medications are governed by the federal Controlled Drugs and Substances Act and cannot be prescribed by NPs until Ontario regulations are amended to enable this practice. For additional information, see questions 21-23.

30. Tylenol #1 can be dispensed at a pharmacy without a prescription. Does this mean that I can prescribe Tylenol #1?
No. NPs are not authorized to prescribe controlled substances, including codeine (a component of Tylenol #1). Under the Narcotic Control Regulations, pharmacists do not need a prescription to  dispense specific preparations containing codeine phosphate. This permission given to pharmacists is not applicable to NP prescribing authority. For further information about these preparations, refer to subsection 36 (1) of the Narcotic Control Regulations.

31. Where can I find information about Ontario’s Narcotics Strategy, and the Narcotics Monitoring System?
Information about Ontario's Narcotics Strategy and the Narcotics Safety and Awareness Act, 2010 can be found on the Ministry of Health's website. As part of the Narcotics Strategy, the province has established the Narcotics Monitoring System (NMS) to monitor the prescribing and dispensing of controlled substances. Although its name implies the monitoring of narcotics, the NMS monitors all controlled substances as well as opioids that are not controlled substances (such as medications containing Tramadol). The main purpose of the NMS is to examine drug use patterns to inform harm reduction strategies and education initiatives, and improve prescribing and dispensing practices related to monitored drugs. If illegal activity or professional misconduct is suspected, the Ministry may report information from the NMS to law enforcement bodies and regulatory colleges.

Dispensing, selling and compounding medication

32. Can I dispense medications that are controlled drugs and substances?

Yes, you can dispense a controlled drug or substance if it has been ordered by a physician or dentist with whom you work. The practice expectations for public protection when dispensing medication are described in the Nurse Practitioner practice standard.

33. I notice that I may be required to put an “identification number” on a medication that I dispense. What is the identification number?

The identification number is assigned to track medications from the point of procurement to the point they are provided to a client. The purpose of an identification number is to trace a medication back to the manufacturer. In the event of safety concerns (e.g., a medication recall), the identification number enables health professionals to follow up with clients appropriately.

You should consult your employer about whether this tracking system exists in your practice setting and how to obtain the identification number. If such a system does not exist, you should advocate for measures to ensure safe medication practices. If you are self-employed, you are expected to establish your own tracking system. The practice expectations for public protection when dispensing medication are described in the Nurse Practitioner practice standard.

34. Why is the drug manufacturer’s name required on the label of a medication I dispense?

Including the manufacturer’s name is another mechanism used for tracking medication. If you are dispensing medication that is stored in its original manufacturer’s packaging, then you are to include this detail on the label of a medication dispensed. However, depending on your practice setting, this information may not be readily available to you. For example, if you are dispensing medication from a supply that is stocked by a pharmacist, the medication may have been re-packaged, and therefore, while this information is available to the pharmacist, it is not available to you. If you do not have access to this information, then you are not required to include it.

When an NP is compounding a cream for topical application, the NP is expected to have the manufacturer’s original packaging for the various substances used in the compound. Therefore, when compounding, you must include the manufacturer’s name on the label if the compound is being dispensed to a client.

35. Is it a conflict of interest for NPs who prescribe a medication to also dispense or sell that medication?

No. The College has developed specific conflict-of-interest provisions to reduce the risk of NPs finding themselves in a position of conflict. For example, NPs cannot charge “dispensing fees” or obtain a profit from the sale of a medication.

NPs cannot obtain any benefit as a result of prescribing, dispensing or selling medication. A “benefit” is defined as any financial or non-financial incentive, whether direct or indirect, that conflicts with an NP’s professional or ethical duty to a client. NPs are expected to base treatment decisions on best available evidence, clinical judgment and client needs. NPs do not prescribe a particular medication because it is available for sale in the practice setting.

The practice expectations for public protection are described in the Nurse Practitioner practice standard.

36. Can NPs sell medication? Can I ask an administrative assistant to conduct the financial transaction associated with selling medication?

Yes, NPs can sell medication. Before you sell a medication, you are accountable for assessing the client to determine that at least one of the following circumstances exists:

• the client does not have reasonable access to a pharmacy
• the client would not otherwise receive the medication
• the client does not have the financial resources to otherwise obtain the medication, or
• the medication is sold as part of a health promotion initiative.

Based on this assessment, if you determine that the client “fits” one of the above circumstances, you can inform the client that he or she may choose to purchase the medication from your practice setting.

NPs cannot charge more than the actual cost of the medication, neither for personal financial gain nor to account for overhead or any other expense incurred.

Although NPs cannot delegate the sale of medication, if the above circumstances are met, an administrative assistant may conduct the financial transaction involved in the sale.

For further information about the practice expectations for public protection when selling medication, see the Nurse Practitioner practice standard.

Performing / ordering procedures

37. Can I apply defibrillation or electrocoagulation?

No. Until the necessary regulations under the Regulated Health Professions Act, 1991 are put in place by government, you must continue to use delegation for applying forms of energy, such as defibrillation or electrocoagulation. For further information about forms of energy, visit NP Practice Resources. 

The College will advise members through its website, its Quality Practice newsletter and The Standard when the regulatory amendments are approved and take effect.

38. Can I perform transvenous cardiac pacing?

No. Although transvenous cardiac pacing is not explicitly listed as a form of energy under the Regulated Health Professions Act, 1991 (RHPA), the College’s interpretation is that this procedure falls under “cardiac pacemaker therapy,” which is listed. Until the necessary regulations under the RHPA are put in place by government, you must continue to use delegation for applying forms of energy. For further information about forms of energy, visit NP Practice Resources.

The College will advise members through its website, its Quality Practice newsletter and The Standard when the regulatory amendments are approved and take effect.

39. Can I reduce a pulled elbow?

Yes. While there are restrictions on the performance of the controlled act associated with “setting” a dislocated joint, you can reduce a radial head dislocation. You would assess the client to confirm that the injury is not more severe (such as a complete elbow dislocation, for which the standards would require you to consult a physician). The practice expectations for public protection when setting fractures and dislocated joints are described in the Nurse Practitioner practice standard.

40. Can I write a client care order for a controlled act procedure (e.g., venipuncture) to be implemented by another nurse?

Yes. Under the Nursing Act, 1991, RNs and RPNs can perform the following controlled acts if the procedure has been ordered by an authorized professional, specifically NPs, physicians, midwives, dentists or chiropodists:

• performing a procedure below the dermis or mucous membrane
• administering a substance by injection or inhalation
• putting an instrument, hand or finger into an artificial opening of the body, or beyond the external ear canal, the point in the nasal passages where they normally narrow, the larynx, the opening of the urethra, the labia majora, or the anal verge.

For further information about the practice expectations for public protection for NPs providing orders, see the Nurse Practitioner practice standard.

Interprofessional practice

41. Do I require a ‘consulting’ physician?
There is no longer a legal requirement for NPs to establish and maintain a consultative relationship with a physician; therefore, you do not require a ‘consulting’ physician. However, the consultation standards have not changed, in that you are expected to consult physicians and other health professionals when you encounter client care needs beyond the legal scope of NP practice or your individual competencies. Furthermore, some employers require NPs to have a consulting physician (see question below).

To make consulting possible, you would establish a network of other health professionals, as appropriate, to meet client care needs. If your current consulting arrangements with physicians meet this objective, then you should continue with those arrangements.

The practice expectations for public protection when providing interprofessional care and consultation are described in the Nurse Practitioner practice standard.

42. I work in a long-term care home. Why is my employer asking for the name of a ‘consulting’ physician with whom I work?
Notwithstanding the information provided in the question above, certain employers may have specific requirements related to NP consultation. For example, regulations of the Long-Term Care Homes Act, 2007 may require an NP to tell the long-term care home the name of the physician with whom the NP has a consultative relationship. NPs should consult their employers to determine whether specific requirements exist.

43. Are pharmacists permitted to prescribe medication?
Under the Ontario Pharmacy Act, 1991, pharmacists are authorized to prescribe medication in certain circumstances outlined below.

Pharmacists may prescribe a medication that is listed in regulation 202/94 under the Pharmacy Act. Currently, the regulation permits pharmacists to prescribe varenicline tartrate and bupropion hydrochloride to assist clients with smoking cessation. The regulation includes conditions that must be in place for a pharmacist to prescribe these medications, including that they have sufficient knowledge, skill and judgment about the drug and the client’s condition, and that they notify the client’s primary health care provider (if any) within a reasonable timeframe.

Pharmacists are permitted to renew a client’s prescription for the purpose of continuity of care. They are also permitted to adapt prescriptions, which means that they may make changes to a client’s prescription by changing the dose, dosage form, directions for use, or route of administration.

Pharmacists cannot renew (refill) or adapt prescriptions for controlled substances or drugs monitored under the Narcotics Safety & Awareness Act, 2010. Pharmacists must notify the prescriber as well as the client’s primary health care provider (if any) when renewing the prescription, or when adapting the prescription if the adaptation is clinically significant, or if notification is necessary to support the client’s care. Pharmacists are expected to do this within a reasonable time frame. For further information, visit the Ontario College of Pharmacists.

NPs are not accountable for a pharmacist’s decision to prescribe, renew or adapt a medication, but they should be aware that this new authority exists. If a pharmacist notifies you that he or she has prescribed, renewed or adapted a prescription for one of your clients, you are expected to document the information in the client’s health record and incorporate it into your clinical decision-making.

Allowing other members of the health care team to prescribe medication increases access to care for clients and emphasizes the need for thorough client assessments, medication histories and interprofessional collaboration and care. The practice expectations for interprofessional care are described in the Nurse Practitioner practice standard.