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Table f Ctets

Itrducti 3

Glssary 4

Stadard Statemets 6

1. Appropriate health care provider 6

2. Authority 7

3. Competence 8

4. Managing outcomes 9

Hw T Apply This Stadard 10

Decision tree 10

Decisions about performing procedures 11

Maitaiig a Quality Practice Settig 12

Suggested Readig 13

Appedix A: Uderstadig the Regulated Health Professions Act, 1991ad the Nursing Act, 1991 14

Appedix B: Ctrlled Acts Established i the Regulated HealthProfessions Act, 1991 16

Continued on next page

Decisis Abut Prcedures ad Authrity,Reised 2006

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Table f Ctets continued

Decisions About Procedures and Authority, Revised 2006 Pub. No. 41071

ISBN 1-897308-92-2

Copyright College of Nurses of Ontario, 2011.

Commercial or for-profit redistribution of this document in part or in whole is prohibited except with the written consent of CNO. Thisdocument may be reproduced in part or in whole for personal or educational use without permission, provided that:

Due diligence is exercised in ensu ring the accuracy of the materials reproduced;

CNO is identified as the source; and

The reproduction is not represented as an of ficial version of the materials reproduced, nor as having been made in affiliation with,or with the endorsement of, CNO.

First published July 1995 as A Guide to Decide: Revised Decision Tree for Performance of ProceduresReprinted January 2000 asA Guide to Decide: A Decision Tree for Performance of ProceduresReprinted October 2000, December 2002, Revised for Web June 2003, Reprinted January 2004, December 2005. Revised October 2006.Reprinted May 2008. Updated June 2009 (ISBN 1-897308-14-0). Updated November 2011 for Bill 179 changes.

Additional copies of this document may be obtained by contacting CNOs Customer Service Centre at 416 928-0900or toll-free in Ontario at 1 800 387-5526.

College of Nurses of Ontario101 Davenport Rd.Toronto, ON M5R 3P1

www.cno.org

Ce fascicule existe en franais sous le titre : La prise de dcisions sur les interventions, revise 2006, no 51071

vISIonLeading in regulatory excellence

MISSIon

Regulating nursing in the public interest

Appedix C: Exceptis t the need fr Authrizati 17

Appedix D: Iitiati f Ctrlled Acts 18

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College of Nurses of Ontario Practice Standard: Decisions About Procedures and Authority, Revised 2006

Nursing standards are expectations that contributeto public protection. They inform nurses of theiraccountabilities and the public of what to expect of

nurses. Standards apply to all nurses regardless of theirrole, job description or area of practice.

College of Nurses of Ontario

ItrductiAs knowledge and technology advance and healthcare environments change, nursing practice evolves.Increasingly, nurses face decisions about performingprocedures that are new, or were previously theresponsibility of other professionals. This practice

document outlines the expectations of nurses whendetermining if: they have the authority to perform a procedure; it is appropriate for them to perform a particular

procedure; and they are competent to perform the procedure.

This document of the College of Nurses of Ontario(the College) allows for flexibility in nursing roleswhile protecting the public interest. It facilitatestimely, efficient access to health care and fosterseffective interprofessional collaboration, whileensuring that appropriate measures are in place topromote safe, effective and ethical client care.

The Decisions About Procedures and Authoritypractice document expands on and replaces thepractice document Guide to Decidewith thefollowing changes to practice. College Council no longer sanctions specific

procedures for delegation4 to nurses. Until thepublication of this practice standard, the Collegeapproved specific controlled act procedures (see

Appendix A) for delegation to nurses througha process called sanctioning. Given the rapid

evolution of health care technologies andpractices, the sanctioning process cannot keeppace with todays nursing practice.

Nurses may consider accepting delegation of anycontrolled act procedure not authorized to nursing aslong as they determine appropriateness as outlined inthis practice standard.

Nurses must fulfil the conditions outlined inthis practice standard before performing anyprocedure related to nursing practice. Thisincludes procedures authorized to nurses in theNursing Act, 1991, those delegated, those carriedout in emergencies and those that do not fallwithin a controlled act.

The College publishes practice standards to: outline the generally accepted expectations

of nurses and set out the professional basis ofnursing practice;

provide a guide to the knowledge, skill, judgmentand attitudes that are required to practise safely;

describe what each nurse is accountable for inpractice; and

achieve public protection when adhered to.

College practice documents apply to all nursesregardless of their roles or areas of practice.This practice document helps nurses, nursingadministrators and employers to make appropriatedecisions about nurses performing procedures,including procedures that require additionalauthority (e.g., delegation). If standards arebreached, it could be professional misconduct.

Making decisions about procedures and authority isa complex issue that can have serious ramifications.This document has organized the factors that a

nurse has to consider when making a decision aboutperforming a procedure.

1 In this document, nurse refers to a Registered Practical Nurse (RPN), Registered Nurse (RN) and Nurse Practitioner (NP).

2 The wordprocedure,for the purpose of this document, includes controlled acts and non-controlled act procedures, as well as actions,activities and/or measures that nurses use in the course of providing client care.

3 In this document, clientmay be an individual, family, group or community.

4 Bolded words are defined in the glossary, which begins on page 4.

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GlssaryThis section defines terminology that is used throughoutthis practice standard. Many of these words have

specific meanings in legislation, and their meanings candiffer from the general understanding of the words ineveryday use.

Authorizing mechanism. An authorizingmechanism is a means by which the authority toperform a procedure is obtained or the decisionis made to perform a procedure. The appropriateauthorizing mechanism depends on the nursescategory or class, role and practice setting.Examples of authorizing mechanisms includeorders, initiation, directives and delegation.

Delegation and orders are distinct authorizingmechanisms, but a delegation may include anorder. For example, an RN or RPN obtains theauthority to adjust cardiac pacemakers througha formal delegation process. The RN or RPNalso needs to know the parameters to adjust thecardiac pacemaker for a particular client. Thedelegation could include criteria describing when itis appropriate to perform the controlled act. (Thiswould replace the need for client-specific orders.)

Alternatively, an order for a particular client couldprovide this information.

Delegation. Delegation is a formal processthat transfers authority to perform a controlledact. A regulated health professional who hasthe legislative authority and the competence toperform a procedure within one of the controlledacts can delegate it to others. This processincludes educating, determining competence

and establishing a process for assessing ongoingcompetence. A written record of the process mustbe kept by the nurse or the employer.

If a procedure has been formally delegated to a nurse,the nurse is authorized to perform the procedureonce it is determined that it is appropriate for aparticular client or group of clients.

Direct client order. A client-specific order canbe an order for a procedure, treatment, drug orintervention for an individual client. An individualpractitioner (e.g., physician, midwife, dentist,chiropodist or NP) directs a specific interventionto be performed at a specific time(s) for a specificclient. A direct order may be written or oral; forexample, given by telephone. Preprinted ordersare supportive tools that require a clients name,the date and an authorizing signature beforeimplementation.

Directive. A directive is an order for a procedure,treatment, drug or intervention that may beimplemented for a number of clients when specif icconditions are met and specific circumstances exist.Most often a directive is a physicians order, and it

is always written. For more information, refer to theColleges practice guideline Directives.

Initiation. Regulations under the Nursing ActgiveRNs and RPNs who meet certain conditions theauthority to initiate specific controlled acts. Thesenurses may independently decide that a specifiedprocedure is required and initiate that procedurein the absence of a direct order or directive. Theconditions are outlined in Appendix D.

There are four standard statements with indicatorsthat describe a nurses accountabilities whenperforming any procedure. Use the Decision Tree

on page 1 and the Decisions About PerformingProcedures chart on page 11 to work through aprocedure relevant to your individual practice.

Appendix A contains an overview of the relevantlegislation concerning authorization and the

performance of procedures, the Regulated HealthProfessions Act, 1991 (RHPA) and the Nursing Act.These acts acknowledge the overlapping scopes of

practice among regulated health professionals. Theyalso provide a flexible framework for changes inpractice to accommodate advances in technology andhealth care.

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While RNs and RPNs have the authority toinitiate, the opportunity may be limited in practiceby legislation, role or practice-setting policy. For

example, the Public Hospitals Act, regulation requires an order from an identified practitioner,such as a NP or physician, for patient treatmentsand diagnostic procedures.

Order. An order is a prescription for a procedure,treatment, drug or intervention. The RHPA,Nursing Actand other legislation, such as the PublicHospitals Act, identify the health care providers whocan provide orders for client care. The order is thedecision to perform the procedure for a particular

client or group of clients. Orders are required when: a procedure falls within one of the three

controlled acts authorized to nursing whenthe nurse does not have the authority toindependently decide to perform (i.e., initiate) theprocedure;

required under the Public Hospitals Act, HealingArts Radiation Protection Actor other legislationgoverning client services; and

required by a practice setting policy or as agreedon within the physicians plan of care.

Professional misconduct. The Nursing Actincludesregulations that identify professional misconduct.Some of the professional misconduct regulations

relevant to a nurses decision to accept delegationand perform procedures, include the following.

1. Contravening a standard of practice of theprofession or failing to meet the standard ofpractice of the profession.

2. Directing a member, student or other healthcare team member to perform nursingfunctions for which she/he is not adequatelytrained or competent to perform.

3. Failing to inform the members employer ofher/his inability to accept specific responsibilityin areas in which specific training is requiredor for which the member is not competent tofunction without supervision.

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Stadard StatemetsThere are four standards, each with accompanyingindicators, that describe a nurses accountabilities

when performing any procedure, whether or not itrequires delegation.

1. Apprpriate health care priderNurses must consider each situation to determineif the performance of the procedure promotes safe

and effective client care, and if it is appropriatefor a nurse to perform the procedure.

Idicatrs

The nurse meets the standard by: having sufficient knowledge, skill and judgment to

determine the appropriateness of performing theprocedure at a given time for a particular client,considering the: clients overall condition,

risks and benefits (e.g., predictability and severityof possible outcomes, risk of harm arising fromperforming or not performing the procedure),

available resources to support the performanceof the procedure (e.g., emergency equipment,cardiac arrest team) and manage outcomes;

advocating for the appropriate health care providerto perform the procedure;

ensuring that the rationale for performing theprocedure is based on achieving the best outcomesfor the client;

determining whether the procedure fits withina professional nursing role (e.g., requires nursingassessment, health teaching, counselling, dischargeplanning);

ensuring that practice setting policies support thenurse in performing the procedure;

declining to perform the procedure when it doesnot support safe, effective and ethical client care;and

ensuring that informed consent includes theinformation that a nurse is performing theprocedure.

In addition, the nurse in an administrativerole meets the standard by: using knowledge, best evidence, skill and

judgment to determine whether a nurse is theappropriate practitioner to perform the procedureafter considering the: specialized knowledge required and whether

nurses can develop the necessary knowledge, skill

and judgment to perform the procedure safely, qualifications required (e.g., the category5 and

class of nursing registration [NP, RN or RPN]),education and related experience,

overall care needs of the client population, risks and benefits (e.g., predictability of

outcomes, risk of harm arising from performingor not performing the procedure), and

whether the rationale for a nurse to performthe procedure supports timely access to care,continuity of care and client care that focuses onthe whole person;

ensuring that sufficient nursing resources areavailable to incorporate the procedure into thepractice (e.g., if nurses take on the procedure,considering how workload is affected andplanning to offset additional responsibilities);

mobilizing sufficient resources to support the safeperformance of the procedure;

providing educational resources to support nurseslearning to perform the procedure safely; and

evaluating client outcomes in relation to nursesperforming the procedure.

5 For more information, refer to the Colleges Utilization of RNs and RPNs practice document.

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2. AuthrityNurses ensure that they have the appropriateauthority before performing procedures.

Idicatrs

The nurse meets the standard by: knowing the scope of practice of nursing, the

legislated authority and what the practice setting hasapproved as a nurses role and responsibilities;

knowing when additional authority is required inthe form of a delegation;

knowing when specific direction for client careis required in the form oforders, directives,

protocols or recommendations; obtaining direct client orders or implementing

directives appropriately; ensuring that client records reflect the procedures

that were performed; initiatingthe performance of controlled act

procedures within the boundaries of legislation,competence and agency policy; and

ensuring that client records reflect the initiatedprocedures.

In addition, the nurse who accepts adelegation meets the standard by: having reason to believe that the health

professional delegating the authority to performa controlled act procedure has both the authorityand competence to perform it;

ensuring that delegation occurs in accordancewith standards of practice;

ensuring that delegation occurs only aftera process for education, determination ofcompetence and assessment of ongoingcompetence has been established;

ensuring that the organization supports nursesperforming the procedure;

advocating for quality assurance mechanisms tomonitor and evaluate the process and outcomes ofdelegation;

accessing appropriate directions, parameters,policies, orders and/or protocols, as required,before performing a delegated procedure;

ensuring that she/he is competent to perform theprocedure;

thinking critically to determine actions and notacting solely on the directions of others;

advocating for required resources before acceptingdelegation; and advocating for a mechanism to resolve issues/

disagreements when a nurse declines to perform aprocedure.6

In addition, the nurse in an administrativerole meets the standard by ensuring that: mechanisms exist to support delegation in

accordance with legislation and/or the standards ofboth the delegator and the nurse(s);

a functional conflict-resolution mechanism existsfor nurses to resolve issues/disagreements regardingperforming procedures;

quality assurance mechanisms monitor the impactof the authorizing mechanism on client care andensure that required changes are made in a timelymanner;

documentation of delegation processes andoutcomes and other authorizing mechanisms aremaintained; and

a process for ongoing monitoring of competenceto perform the delegated procedure(s) is in place.

6 For more information, refer to the Colleges practice documents Disagreeing With the Plan of Care and Refusing Assignments and

Discontinuing Nursing Services.

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3. CmpeteceNurses ensure that they are competent in boththe cognitive and technical aspects of a procedure

prior to performing it.

Idicatrs

The nurse meets the standard by: demonstrating cognitive and technical competence

to perform the procedures; declining to perform procedures that she/he is not

competent to perform; determining the appropriateness of the procedure

for the specific client in a specific situation;

demonstrating knowledge of the followingcomponents of procedures: purpose (assessment or treatment), indications, contraindications, risk to the client, expected outcomes, actions to take if complications occur, and health teaching and decision support;

applying knowledge, best evidence, skill, judgmentand appropriate authority to make and act ondecisions required during the procedure;7

consulting when she/he reaches the limits of her/his knowledge, skill and judgment;

communicating with other health care teammembers as necessary for safe, effective andethical client care; and

reflecting on and continuously improving

knowledge, skill and judgment in relation topractice.

In addition, the nurse in an administrativerole meets the standard by: ensuring that resources support the delivery of

initial and ongoing education to support nurses inattaining and maintaining competence.

7 The ability to make decisions during a procedure and then to act on those decisions involves interpreting and analyzing information as it

is gathered and using knowledge, skill and judgment. It also involves having the appropriate authority to act on the information gained

during the procedure. In many instances, the need to interpret and analyze information in this manner does not rest solely with the

nurse; rather, it is a collaborative process involving other health care providers.

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Decisi tree

Appropriate care

provider?

Proposed procedure

Emergency?

Do not perform

Not a

controlled act

Controlled act not

authorized to nursing

May

perform

Controlled act

authorized to nursing

Do you have the knowledge,

skill and judgment to performand manage all possible

outcomes of performing the

procedure?

If an order isrequired, is it

in place? Delegation in

place?

Initiated*?

Do not

perform

Do not

perform

Do not

perform

* Only applies to controlled act procedures authorized

to nursing, as identified in Appendix D.

Hw T Apply This StadardUsing the knowledge gained from reading DecisionsAbout Procedures and Authority, Revised 2006work

through a procedure relevant to your individualpractice with the help of the following two charts.

YES

no

no YESYES

no YES

YES no

no

YES no

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Decisis abut perfrmig prcedures

Practice setting planning

considerations

Individual nurse considerations

Client What are the care requirements of the client

population? What are the associated benefits and risks? Will nursing involvement support safe,

effective and ethical client care?

Is this procedure appropriate for this client at

this time in this situation? What are the associated benefits and risks?

Nurse What competencies are required to perform

the procedure safely, effectively and ethically? Can nurses develop the necessary

knowledge, skill and judgment to perform

the procedure safely? Which nursing category and what level of

experience and education are necessary? Will there be support for continuing

education programs for nurses to attain and

maintain competence? If the procedure is added, what impact

will it have on the nurses ability to provide

nursing services (health teaching, emotional

support)? How will this impact be addressed?

Do I have the necessary knowledge, skill and

judgment to:

a. assess the appropriateness of performing

the procedure?

b. perform the procedure?

c. manage the client during and after the

procedure? How will I attain/maintain my competence? Do I have the authority to perform the

procedure? Do I have the authority to manage the client's

care while performing the procedure?

Environment

Is the procedure within the documentedrole description of the provider identified to

perform the procedure? What authorizing mechanisms are needed to

perform the procedure? What value does nursing add to the

performance of the procedure? Are the necessary human and material

resources available and accessible now and

in the future to support safe, effective and

ethical client care?

Is the performance of the proceduresupported in my practice settings role

expectations? Are the necessary resources available to

support me in providing safe, effective and

ethical client care during and after performing

the procedure? Will these resources continue to be available

whenever the procedure is performed?

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Suggested Readig

College of Nurses of Ontario. (1). Draft

regulations. Communiqu, 1(), pp -2.

College of Physicians and Surgeons of Ontario.(2). Delegation of Controlled Acts. [Policy]Retrieved March 2, 2, fromwww.cpso.on.ca/policies/delegation.htm.

College of Respiratory Therapists of Ontario.(2). Delegation of Controlled Acts. Toronto:Author.

de Marzo, D.L. (13). Policies and procedures:Protection or peril? RN, (), pp 1-2, .

Hewitt-Taylor, J. & Melling, S. (2). Careprotocols: Rigid rules or useful tools? PaediatricNursing, 1(), pp 3-3.

Liswood, J. & Ellis, B. (21). The solution is inthe people. Toronto: Miller Thompson LLP.

Ontario College of Pharmacists. (1). Delegationof dispensing. Toronto: Author. Retrieved July12, 2, at www.ocpinfo.com/client/ocp/OCPHome.nsf/web/Delegation+of+Dispensing!OpenDocument.

Parent, D., & Kelly-Nichols, J. (23). Decision treefor additional skills. Canadian Nurse, (), pp2-2.

Richards, A., Carley, J., Jenkins-Clarke, S. &Richards, D.A. (2). Skill mix between nursesand doctors working in primary care delegation

or allocation: A review of the literature.International Journal of Nursing Studies, 3(3), pp1-1.

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Appedix A: Uderstadig theRegulated Health Professions Act, 1991ad the Nursing Act, 1991

Nurses are expected to practise in accordancewith both the practice standards published by theCollege and relevant legislation. The followingoverview of the RHPA and the Nursing Actfocuseson controlled acts and the authority of nursesto perform controlled acts. Understanding thelegislative framework is critical to being able tomake safe decisions about performing proceduresand ensuring that nursing practice is consistent withthe Colleges practice documents.

Regulated Health Professions Act: Scpe fpractice, ctrlled acts mdelThe scope of practice model set out in the RHPAcontains two elements:1. a scope of practice statement; and2. controlled acts authorized to the profession.

This model provides a flexible framework thatfacilitates the evolution of the roles of healthprofessionals and their respective scopes of practice.

Nursing Act: Scpe f practice statemetAll regulated health professions have a profession-specific act with related regulations that govern theprofession. In the case of nursing, the Nursing Actcontains a scope of practice statement that describesin a general way what the profession does and themethods that it uses. The scope of practice is notexclusive or protected; it does not prevent othersfrom performing the same procedures. The RHPAacknowledges that the scopes of practice of varioushealth professions overlap.

The scope of practice statement for nursing is:The practice of nursing is the promotion of healthand the assessment of, the provision of, care for, andthe treatment of, health conditions by supportive,preventive, therapeutic, palliative and rehabilitativemeans in order to attain or maintain optimalfunction.

Ctrlled actsThe RHPA established 13 controlled acts. (SeeAppendix B.) Controlled acts are considered

potentially harmful if performed by unqualifiedpeople.9

A regulated health professional is authorized toperform a portion or all of the specific controlledacts that are appropriate for that professionals scopeof practice. Because of overlaps in practice, someprofessionals are authorized to perform the same, orparts of the same, controlled acts.

While nursing practice includes the performance

of authorized controlled acts, the nursing roleand scope of practice is broader than executingcontrolled acts. Performing controlled acts representsonly a small portion of professional nursing practice.

It is important to note that: controlled acts are not the only procedures that

may cause harm; having the authority to perform a procedure does

not automatically mean it is appropriate to do so;and

each nurse is accountable for her/his decisions andactions.

Ctrlled acts authrized t Rns adRPnsRNs and RPNs are authorized to perform thefollowing three controlled acts under the Nursing Act.1. Performing a prescribed procedure below the

dermis or a mucous membrane.2. Administering a substance by injection or

inhalation.3. Putting an instrument, hand or finger

i. beyond the external ear canal,ii. beyond the point in the nasal passages where

they normally narrow,iii. beyond the larynx,iv. beyond the opening of the urethra,v. beyond the labia majora,vi. beyond the anal verge, orvii. into an artificial opening into the body.

9 The RHPA includes a number of exceptions that permit persons who are not members of a regulated profession to perform controlled

acts in defined circumstances. These exceptions are described in Appendix C.

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An RN or RPN is authorized to perform aprocedure within the controlled acts authorized tonursing:

if initiated (see Appendix D) in accordance withconditions identified in the regulation; or

if the procedure is ordered by a physician, dentist,chiropodist, midwife or NP.

Ctrlled acts authrized t nPsNPs have successfully completed an approvededucation program and passed an examination togive them the authority under the Nursing Acttoperform the following controlled acts.1. Communicating to a client or a clients

representative, a diagnosis made by the NPidentifying as the cause of a clients symptoms, adisease or disorder.

2. Performing a procedure below the dermis or amucous membrane.

3. Putting an instrument, hand or finger,i. beyond the extarenal ear canalii. beyond the point in the nasal passages

where they normally narrowiii. beyond the larynxiv. beyond the opening of the urethrav. beyond the labia majoravi beyond the anal verge, orvii. into an artificial opening of the body.

. Applying or ordering the application of aprescribed form or energy.

. Setting or casting a fracture of a bone ordisclocation of a joint.

. Administering a substance by injection orinhalation, in accordance with the regulation,or when it has been ordered by another healthcare professional who is authorized to order theprocedure.

. Prescribing, dispensing, selling or compounding adrug in accordance with the regulation.

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Appedix B: Ctrlled ActsEstablished i the Regulated HealthProfessions Act, 1991

The RHPA established 13 controlled acts. Aregulated health care professional is authorized toperform a portion or all of the specific controlledacts that are appropriate for the professionals scopeof practice.

1. Communicating to the individual or his/herpersonal representative a diagnosis identifyinga disease or disorder as the cause of symptomsof the individual in circumstances in whichit is reasonably possible that the individual or

his/her personal representative will rely on thediagnosis.

2. Performing a procedure on tissue belowthe dermis, below the surface of a mucousmembrane, in or below the surface of thecornea, or in or below the surfaces of the teeth,including the scaling of teeth.

3. Setting or casting a fracture of a bone ordislocation of a joint.

. Moving the joints of the spine beyond theindividuals usual physiological range of motionusing a fast, low-amplitude thrust.

. Administering a substance by injection orinhalation.

. Putting an instrument, hand or finger:i. beyond the external ear canal,ii. beyond the point in the nasal passages

where they normally narrow,

iii. beyond the larynx,iv. beyond the opening of the urethra,v. beyond the labia majora,vi. beyond the anal verge, orvii. into an artificial opening into the body.

. Applying or ordering the application of a formof energy prescribed by the regulations underthis Act.

. Prescribing, dispensing, selling or compoundinga drug as defined in clause 113(1)(d) ofthe Drug and Pharmacies Regulation Actor

supervising the part of a pharmacy where suchdrugs are kept.

. Prescribing or dispensing, for vision or eyeproblems, subnormal vision devices, contactlenses or eye glasses other than simplemagnifiers.

1. Prescribing a hearing aid for a hearing-impairedperson.

11. Fitting or dispensing a dental prosthesis,orthodontic or periodontal appliance or a deviceused inside the mouth to protect teeth fromabnormal functioning.

12. Managing labour or conducting the delivery ofa baby.

13. Allergy-challenge testing of a kind in which apositive result of the test is a significant allergicresponse.

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Appedix C: Exceptis t the needfr AuthrizatiThe Regulated Health Professions Act, 1991 provides

several exceptions that allow persons who are notauthorized as members of a regulated profession toperform controlled acts. They are as follows: when providing first aid or temporary assistance

in an emergency;0 when, under the supervision or direction of a

member of the profession, a student is learningto become a member of that profession and theperformance of the procedure is within the scopeof the professionals practice;

when treating a member of a persons household

and the procedure is within the second or thirdcontrolled act authorized to nursing; when assisting a person with his/her routine

activities of living and the procedure is withinthe second or third controlled act authorized tonursing; or

when treating a person by prayer or spiritualmeans in accordance with the religion of theperson giving the treatment.

In addition, a person who performs the followingprocedures is not considered to be in contraventionof the RHPA: ear piercing or body piercing forthe purpose of accommodating a piece of jewelry,electrolysis and tattooing. Other exceptions includemale circumcision as part of a religious traditionor ceremony, and taking a blood sample by aperson employed by a laboratory licensed under theLaboratory and Specimen Collection Centre LicensingAct.

Emergecy situatisThe RHPA allows members of the public and

regulated health care providers to performcontrolled acts without authorization whenproviding first aid or temporary assistance inan emergency. Emergency procedures that areperformed within a health care facility technicallymeet the emergency exception. The Collegemaintains, however, that in situations in which it

is anticipated that emergencies will likely occur,such as in a hospital or long-term care facility, it isnecessary to have a standardized process to enable

nurses to attain and maintain competence inperforming emergency procedures that are outsidethe controlled acts authorized to nursing. Thisprocess includes the: education and ongoing assessment of competence

with the involvement of a health professionalauthorized and competent to perform theprocedure;

documentation of the process; written criteria to select appropriate clients and

identify treatment parameters; and necessary authority and/or resources to manage

client outcomes.

Such a process helps to ensure that nurses have thenecessary preparation to perform a procedure thatcarries a risk of harm. This process is in keepingwith the intent of the controlled acts model and theColleges mandate to protect the public.

10 Emergency exemption applies to anyone, including nurses, when providing first aid or temporary assistance in an emergency.

11 Procedures are considered to be routine activites of living when the need for the procedure, the response to the procedure and the

outcomes of performing the procedure have been established over time and, as a result, are predictable.

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Appedix D: Iitiati f CtrlledActsRegulations under the Nursing Act, 1991 give

RNs and RPNs who meet certain conditions theauthority to initiate specific controlled acts. RNsand RPNs may independently decide that a specificprocedure is required and initiate the procedurein the absence of a specific order or directive (e.g.,from a physician or NP).

While RNs and RPNs have the authority under theregulations to initiate, in practice the opportunityto initiate may be limited by other legislation orpractice setting policy. For example, regulation

of the Public Hospitals Actrequires an order fortreatment and diagnostic procedures.

If initiating is within the scope of the RN or RPNsrole and competence, the initiating RN or RPNmay perform the procedure, or an RN may writethe order and another nurse may perform it. Safe,appropriate initiation of a procedure involves: assessing the client and identifying a problem; considering all of the available options to address

the problem; weighing the risks and benefits of each option

considering the clients condition; deciding on a course of action; anticipating the management of potential

outcomes; and accepting sole accountability for deciding that

the particular procedure is required and ensuringthat any potential consequences are managedappropriately.

Any RN or RPN who initiates a procedure mustmeet all of the following conditions: has the knowledge, skill and judgment to perform

the procedure safely, effectively and ethically; has the knowledge, skill and judgment to

determine whether the clients condition warrantsthe performance of the procedure;

determines that the clients condition warrantsperformance of the procedure having considered: the known risks and benefits to the individual, the predictability of the outcomes of performing

the procedure, the safeguards and resources available in the

circumstances to safely manage the outcomes ofperforming the procedure, and

other relevant factors specific to the situation;

and accepts accountability for determining that the

clients condition warrants the performance of theprocedure.

Not all RNs or RPNs will be competent to initiatecontrolled act procedures, and not all nursing roleswill include initiation. RNs or RPNs who considerinitiating procedures are advised to clarify the scopeof their roles and responsibilities within the healthcare team and with their employers.

The chart on page 1 lists the procedures that maybe initiated (performed and/or ordered) by RNs andRPNs who meet the conditions described above.

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Prcedures that may be iitiated by Rns ad RPns accrdig t the Nursing Act

An RPN may initiate but cannot order

another nurse to perform

An RN or NP may initiate and/or provide an

order for an RN or RPN to perform

Care of a wound below the dermis or below a mucous

membrane: cleansing soaking dressing

Care of a wound below the dermis or below a

mucous membrane: cleansing soaking irrigating probing debriding packing dressing

Venipuncture to:establish peripheral venous access and maintain

patency when client requires medical attention

and delaying venipuncture is likely to be harmful

0.9% NaCl only

For the purpose of assisting client with health

management activities that involve putting an

instrument beyond the:point in the nasal passages where they normally

narrow larynx opening of the urethra

For the purpose of assisting client with health

management activities that involve putting an

instrument beyond the:point in the nasal passages where they normally

narrow larynx opening of the urethra

For the purpose of:assisting client with health management activities

Procedure that requires putting a hand or finger

beyond the: labia majora

For the purpose of: assessing clientassisting client with health management activities

Procedure that requires putting an instrument,

hand or finger beyond the: labia majora

For the purpose of: assessing client assisting client with health management activities

Procedure that requires putting an instrument orfinger beyond the: anal verge

For the purpose of: assessing client assisting client with health management activities

Procedure that requires putting an instrument orfinger beyond: the anal verge an artificial opening into clients body

Procedures that involve putting an instrument or finger into one of the body openings or into an artificialopening of the body for the purpose of treating a health problem cannot be initiated by a General Class RNor RPN. Authorized procedures are also limited to those procedures that do not require the use of a prescribeddrug, as nurses in the General Class are not authorized to prescribe drugs.

For information about controlled acts that NPs can perform, refer to the Nurse Practitionerpractice documentatwww.cno.org/docs.

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101 Davenport Rd.

Toronto, ON

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www.cno.org

Tel.: 416 928-0900

Toll-free in Ontario: 1 800 387-5526

Fax: 416 928-6507

E-mail: [email protected]

Documents

41071 Decisions