Nursing Practice Updates

There is an updated dose of Azithromycin as a third-line oral antibiotic agent within the Pharyngitis: Adult and Pediatric CDT. This change takes effect immediately and is posted on the CRNS website along with all of the CDTs for RN(AAP) practice. 

The change in Adult and Pediatric dosing and duration of Azithromycin is consistent with the RxFiles: Drug comparison charts (13th ed.), and is as follows: 

If you have any questions, CRNS Practice Advisors are available by emailing practiceadvice@crns.ca.

Reference

RxFiles Academic Detailing Program. (2021). RxFiles: Drug comparison charts (13th ed.). Saskatoon Health Region.

The 2022 Bylaws package was presented to registrants for their approval at the annual meeting on May 5, 2022. All proposed bylaw amendments were approved which allowed CRNS to follow the established government processes for finalizing the bylaws. Administrative bylaws were filed with the Information Services Corporation (ISC) following the annual meeting and we received written approval from them on May 31, 2022. Regulatory bylaws were submitted to the Ministry of Health for Ministerial approval in June. These bylaws were approved and published in the September 9, 2022, Saskatchewan Gazette which brings them into force and effect. 

What this means for registrants is that the 2022 Bylaws are being updated and are now posted on the CRNS website for review. On November 1, 2022, all registrants will be required to comply with these bylaws. Some of the key regulatory bylaw amendments are listed below:

• Continuing Competence Program (CCP) requirements for the revised program will be implemented for the upcoming 2023 registration year which begins on December 1, 2022. The new requirements have been outlined in Bylaw V.1 Continuing Competence. 
• To fulfill the CRNS mandate of protection of the public, all practicing members in every category must report to the Registrar by email or phone, as soon as is reasonably practical, a charge under the Criminal Code (Canada), the Controlled Drugs and Substances Act (Canada) or any similar legislation in any province, territory, state, or country, or any charge concerning the practice of nursing or another profession in any jurisdiction. This amendment can be found in Bylaw VI Membership.
• Bylaw VI Categories of Practice, Section 3 Nurse Practitioner Category contains a change for NP practice. It enables NPs to order or request medical imaging involving the application or detection of forms of energy for diagnostic and screening purposes and to receive and interpret reports, or to perform ultrasound imaging for the sole purpose of point of care diagnostic assistance when it is in the best interest of the client, in accordance with their practice standards and code of ethics, when they have the competence and judgment to safely do so, when it is in alignment with best practice evidence and when agency policy permits. This is an important amendment that facilitates increased access to timely care for the residents of Saskatchewan. 
• Another bylaw that impacts NPs directly is Bylaw VI Categories of Practice, Section 4 Prescription Review Program as the language has been updated to reflect current best practices on providing prescriptions directly to a pharmacy. 
• A new section was added to Bylaw VI Categories of Practice, Section 5 Resignation on Medical or Other Grounds. This bylaw essentially allows a CRNS registrant who identifies that their fitness to practice is significantly impacted by the effects of a physical or mental disability and choose to resign from practice to protect the safety of patients. The bylaw outlines the conditions of this process. 
• Bylaw XV adopts the recently published RN with Additional Authorized [RN(AAP)] Practice Standards as the standards required of registered nurses practicing with Additional Authorized Practice, so this will be of special interest to RN(AAP)s and managers or interdisciplinary colleagues of RN(AAPs). The 2022 RN(AAP) Practice Standards will be posted online in the upcoming weeks.

Some of the key administrative bylaw amendments are listed below:

• The Canadian Nurses Association (CNA) officially changed their membership structure at their 2021 annual meeting and this was implemented on January 1, 2022. Jurisdictional Membership will not exist going forward. Instead of organizations representing nurses as members, individual nurses will obtain their own memberships. Therefore, Bylaw I, Section 6 and Bylaw VII Fees, Sections 3 and 4 have all been updated to reflect this. This is important for registrants to be aware of because CRNS will no longer be collecting CNA fees during license renewal. Should registrants wish to be CNA members, they can do so independently by following this link.
• Bylaw VII Fees also contains wording regarding fees for practicing registrants currently licensed in a jurisdiction whose nursing regulatory body has signed a multijurisdictional agreement with the council to provide virtual care in Saskatchewan. 

Should you have questions regarding the 2022 Bylaws, contact a Nursing Practice Advisor by email at practiceadvice@crns.ca or by phone at 1.800.667.9945.

Registered Nurses (RN) may be authorized by a Nurse Practitioner (NP) to administer bioactive agents such as Botox. The CRNS has collaborated with the College of Physicians and Surgeons of Saskatchewan (CPSS) over the past several months to obtain written clarification on this matter and is able to share this update. 

Prior to initiating practice, RNs administering and NPs administering and/or authorizing bioactive agents require recognition of practice through the CRNS Regulatory Services team. 

RNs and NPs must have the ongoing knowledge, skill and judgement to safely perform the injection of bioactive agents. NPs authorizing this practice must also supervise the RN to reasonably assure safety for clients. The administration of bioactive agents is beyond entry-level practice and requires an RN Clinical Protocol that includes the essential components of an RN Specialty Practice. 

Further guidance on including alternative and complementary therapies into RN and NP practice can be found in thisNursing Practice Update.

CRNS Nursing Advisors are available by emailing Regulatory Services at regulation@crns.ca or Nursing Practice at practiceadvice@crns.ca.

The Canadian Council for Registered Nurse Regulators (CCRNR) Nurse Practitioner Regulation Framework Implementation Plan Project (NPR-FIPP) continues to move forward. All project updates can be found on the CCRNR website. 

If you’d like to stay up-to-date on this project, you can subscribe to the CCRNR NPR-FIPP newsletter when you visit CCRNR website. The CRNS will be setting up meetings to inform partners of the project and involve key stakeholders in consultation. 

If you are interested in learning more about this project, email Donna Cooke, Nursing Advisor, at dcooke@crns.ca.

Nursing Practice Update: Amendments to the Criminal Code to protect health care workers and people seeking access to health services

Changes to the Criminal Code came into effect on January 16, 2022, and serve to enhance protection for health care workers and people seeking access to health services. Violence and threats of violence towards Registered Nurses and other health care workers is a long-standing issue that has worsened during the COVID-19 pandemic and has extended to the public who are seeking health services. A backgrounder from the Government of Canada is available here.

The Canadian Nurses Protective Society (CNPS) has written an article further describing the changes to the Criminal Code and how they may intersect with Registered Nurses as health care professionals.

CRNS members are encouraged to read the linked articles in this update to become familiar with the legislation changes.

Questions? Contact an CRNS Practice Advisor by phone at 1.800.667.9945 or 306.359.4227, or by email at practiceadvice@crns.ca.

The CRNS is updating direction to its members who assign tasks to unregulated care providers. The CRNS is seeking feedback on this resource from members and external stakeholders, including the public, as part of the external consultation process. This process is in place to ensure relevant information is clearly presented. Feedback can be provided by accessing this survey and will be accepted until Monday, January 31, 2022 at 4:30pm.

Final approval of the resource is through the CRNS Executive Director. Questions or comments are welcome and can be directed to tbelcourt@crns.ca.

Effective March 31, 2022, tramadol will be removed from the Prescription Drug List (PDL) and listed in Schedule 1 of the Controlled Drugs and Substances Act (CDSA). Tramadol will also be listed as item 19 in the Schedule of the Narcotic Control Regulations (NCR). This means that tramadol will be subject to all the regulatory requirements set out in the CDSA and NCR. The rational to change the listing is to reduce risks to human health, and to facilitate the detection and prevention of diversion of tramadol.

For a full explanation, including impact to practice, please visit:

https://gazette.gc.ca/rp-pr/p2/2021/2021-03-31/html/sor-dors43-eng.html

If you have any question about your NP practice, please contact practicadvice@crns.ca.  If you have any questions about prescribing controlled drugs and substances or the CRNS

Prescription Review Program, please contact prp@crns.ca

The number of RNs and NPs engaging in alternative or complementary therapies, such as aesthetics, through non-traditional employers or self-employed practice, has increased in recent times.  These practices require assessment by the College of Registered Nurses of Saskatchewan (CRNS) to determine if the activity is recognized as registered nursing practice. Being engaged in self-employed practice brings certain opportunities as well as inherent risks, therefore it is important for RNs and NPs interested in and/or practicing in these areas to:

• Consult with a Nursing Practice Advisor to discuss your practice situation and receive guidance on next steps;
• Consult with a Regulatory Services Nursing Advisor to discuss the Recognition of Practice process;
• Refrain from using the RN or NP title until the activity has been recognized as nursing practice by the CRNS;
• Ensure that the necessary resources, including but not limited to, supplies to manage untoward events, policy/procedure manual, are in place for safe patient care;
• Ensure that you have the appropriate authority to conduct the activities; and,
• Refrain from including hours worked in these areas in self-reported RN or NP practice hours until the activity has been recognized as nursing practice by the CRNS.

As the landscape of alternative and complementary therapies grows and changes, the CRNS applies principles of right touch regulation when working with members to reasonably assure accountable professional practice. The CRNS lives this by applying consistent and transparent processes, providing decisions that are proportionate to the risk posed and by showing agility to adapt to change while keeping the focus on public safety.

CRNS Nursing Advisors are available by emailing:

Regulatory Services at regulation@crns.ca or

Practice at practiceadvice@crns.ca.

The CRNS is pleased to announce the release of an updated nursing practice guideline, Medical Assistance in Dying Guideline, 2021. The guideline has been updated to reflect current, evidence-informed best practices, legislative changes and applies to all categories of nursing practice.

Please review this document and consider how it may relate to your practice. If you have any questions, please contact a CRNS Practice Advisor by phone at 1.800.667.9945 or 306.359.4227 or by email practiceadvice@crns.org.

The current Health Canada section 56 exemption for all drugs under the Controlled Drugs and Substances Act (CDSA) that was set to expire on September 30, 2021, has been extended to September 30, 2026. The purpose of the exemption was to reduce regulatory barriers to support the continuity of care for patients, and as the pandemic continues and Health Canada works toward modernizing federal regulations, the extension to September 30, 2026, meets these continued needs. The Saskatchewan Prescription Review Program partners – Ministry of Health, Saskatchewan College of Pharmacy Professionals, College of Registered Nurses of Saskatchewan, College of Physicians and Surgeons, and the College of Dental Surgeons of Saskatchewan – have considered the long-term implications of the exemption, with a focus on patient safety and access.

This exemption provides prescribers, including Nurse Practitioners, the authority to issue a verbal prescription for controlled substances drugs to extend or refill a prescription. The Saskatchewan Prescription Review Program partners have agreed to accept the new exemption with the following two provisions for Saskatchewan:

• CDSA drugs may only be transferred once within Saskatchewan. While there remains risk of diversion of medications, the Patient ID Policy alleviates some risk and permitting one transfer may benefit the patient.
• Verbal prescription orders should only be accepted after every effort has been made to receive a written or e-prescription from a provider. The rationale for accepting a verbal order must be documented by the pharmacist.

As previous, Health Canada can terminate this exemption depending on the current conditions if the Minister deems that such suspension is necessary to protect public health, safety or security. If necessary, the Minister may change the terms and conditions of this exemption. Should this be the case, you will be informed. Read the Full Statement

The CRNS is pleased to announce the release of an updated nursing practice guideline, Medication Management Guideline. The guideline has been updated to reflect current, evidence-informed best practices and applies to all categories of nursing practice.

Please review this document and consider how it may relate to your practice. If you have any questions, please contact an CRNS Practice Advisor by phone at 1.800.667.9945 or 306.359.4227 or by email practiceadvice@crns.ca.

Ivermectin for prophylaxis or treatment of COVID-19 has been promoted on social media and is not supported by scientific evidence. In humans, ivermectin is only approved for treatment of parasitic infections and rosacea.

Based on the current scientific evidence and best-practice guidelines, the College of Physicians and Surgeons (CPSS), the College of Registered Nurses of Saskatchewan, the Saskatchewan College of Pharmacy Professionals, the Saskatchewan Medical Association, and the Pharmacy Association of Saskatchewan disapprove of the use of ivermectin for either treatment or prophylaxis for COVID. This opinion is further supported by the evidence from Health Canada, the World Health Organization (WHO), Alberta Health Services Covid-19 Scientific Advisory group, and the British Columbia COVID-19 Therapeutics Committee guidance document.

The joint statement is available here.

If you have any questions, please contact an CRNS Practice Advisor by phone at 1.800.667.9945 or 306.359.4227 or by email practiceadvice@crns.ca.

Industry sponsorship consists of any interest: personal; business; commercial; political; academic; or financial offered by a private, for-profit, or commercial enterprise as part of its marketing and public relations efforts. When encountering industry sponsorship, Registered Nurses (RN) and Nurse Practitioners (NP) must be aware of conflicts of interest. A conflict of interest can be an actual, perceived or potential conflict between the professional duty of an RN or NP and their private interests. A conflict of interest can occur when the RN or NP is in a position to make a decision based upon what is beneficial to their individual interests (i.e., deriving personal benefit [Traversy et al., 2021]) and not in the best interest of the client.

RNs and NPs can engage in ethical considerations for industry sponsorship to ensure safe, competent and ethical care for clients in Saskatchewan by:

• Reflecting on and practicing according to current CRNS practice documents, including:
• • The Registered Nurses Act, 1988; CRNS bylaws; CNA Code of Ethics for Registered Nurses; Registered Nurse Practice Standards; Registered Nurse Entry-Level Competencies; Registered Nurse (Nurse Practitioner) Practice Standards; Registered Nurse (Nurse Practitioner) Entry-Level Competencies; and other CRNS documents as appropriate.
• Understanding the employer’s conflict of interest policy. If a conflict of interest policy does not exist, advocate for policy that addresses conflict of interest.
• Identifying and seeking to avoid conflict of interest to ensure the maintenance of public trust.
  • Any conflict of interest must be resolved in favour of the interest of the client receiving care.
• Being fully transparent and fully disclosing any actual, perceived or potential conflict of interest when engaging in industry sponsorship.

This nursing practice update replaces the former CRNS Ethics Guidelines for Industry Sponsorship, 2015.

Questions or comments are welcome and can be directed to practiceadvice@crns.ca or by phone: 306.359.4200 or 1.800.667.9945 (toll-free within Canada).

Resources:
• RN Practice Standards
• RN Entry-Level Competencies
• CNA Code of Ethics (2017)
• Registered Nurse (Nurse Practitioner) Entry-level Competencies (ELC)s CRNS
• Registered Nurse (Nurse Practitioner) Practice Standards CRNS
• Self-Employed Practice Guideline

Reference:
Traversy, G., Barnieh, L., Akl, E. A., Allan, G. M., Brouwers, M., Ganache, I., … & Tonelli, M. (2021). Managing conflicts of interest in the development of health guidelines. CMAJ, 193(2), E49-E54.

Registered nurses (RN) are responsible and accountable to provide evidence-based, safe, competent and ethical nursing care in all practice settings. In the emergency department, “the process of triage is essential for safe and appropriate care of the emergency department patient” (National Emergency Nurses Association [NENA], 2019).

In 2019, NENA revised their position statement, Role of the Triage Nurse and includes the following key points:

• Triage is a sorting process that requires rapid assessment, critical thinking and application of a standard set of guidelines with patients that can experience instability and changes to their condition.
• The process of triage is best carried out by RNs and Nurse Practitioners (NP) with emergency nursing expertise who have completed a triage-specific educational program.

RNs and NPs work in the emergency department as part of a multidisciplinary team, where safe and appropriate care is best achieved through collaboration and respect.

This nursing practice update replaces the former Triaging in Emergency Departments CRNS and SALPN Joint Statement, 2013.

If you have questions, please contact an CRNS Practice Advisor by phone at 1.800.667.9945 or 306.359.4200 or by email practiceadvice@crns.ca

Reference:

National Emergency Nurses Association. 2019. Role of the Triage Nurse. Retrieved from https://nena.ca/w/wp-content/uploads/2014/11/Role-of-the-Triage-Nurse-2.pdf

Following feedback from Canadians, experts, practitioners, stakeholders, Indigenous groups, provinces and territories, changes were made to Medical Assistance in Dying legislation which took effect on March 17, 2021.

In response, the CRNS has revised and updated the Guidelines for RN Involvement in Medical Assistance in Dying and the Guidelines for NP Involvement in Medical Assistance in Dying.

The new document Medical Assistance in Dying identifies the changes to the legislation as well as combines the two previous documents into one document. The CRNS is seeking feedback from members, stakeholders and the public related to the new document. Please access the document here. Please access the survey questions here. The CRNS would appreciate any feedback by July 13, 2021, at 4:30 pm.

Final approval of the document is through the CRNS Executive Director and CRNS Council. The document will take effect on the day of CRNS Council approval.

Questions or comments are welcome and can be directed to creece@crns.ca.

On June 1, 2021, The Coroners Amendment Act, 2019 and The Coroners Amendment Regulations, 2021 came into force making several changes to The Coroners Act, 1999 and The Coroners Regulations, 2000. There are a couple of changes that may be important for Nurse Practitioners (NP) to be aware of with respect to the reporting of deaths resulting from medical assistance in dying (MAiD). The changes include:

1. The definition of “medical assistance in dying” as defined in section 241.1 of the Criminal Code has been moved from The Coroners Regulations, 2000 to Section 2 of The Coroners Act, 1999.

2. Subsection 7(4) has been added to The Coroners Act, 1999 which clarifies that the reporting requirements under section 7 do not apply with respect to a person who died as a result of medical assistance in dying where the underlying cause leading to death is natural, i.e. from a natural disease process.

3. Subsection 7(5) has been added which requires an NP to report a death resulting from medical assistance in dying to a coroner if the underlying cause leading to the death is unnatural, i.e. from injury rather than disease.

If you have questions, please contact an CRNS Practice Advisor by phone at 1.800.667.9945 or 306.359.4200 or by email practiceadvice@crns.ca.

As per the safety alert from Health Canada, there is a significant recall of Angiotensin II Receptor Blockers (ARBs) including irbesartan, losartan and valsartan due to an azido impurity. To ensure the continuity of care for patients using ARBs, the Registrar for the Saskatchewan College of Pharmacy Professionals (SCPP) has passed emergency exemptions that allow pharmacists to prescribe therapeutic substitutions, in collaboration with the College of Physicians and Surgeons of Saskatchewan, the College of Registered Nurses of Saskatchewan and the Ministry of Health. See the joint recall notification. 

If you have questions, please contact an CRNS Practice Advisor by phone at 1.800.667.9945 or 306.359.4200 or by email practiceadvice@crns.ca.

The CRNS is pleased to announce the release of a new Social Media resource. This resource has been created using current information and feedback from CRNS members and the public. The resource provides guidance and recommendations to CRNS members who utilize social media both inside and outside the workplace. The resource offers strategies to balance advocacy and engagement while also adhering to the practice standards and the code of ethics.

Please review this document and consider how it may relate to your practice. If you have any questions, please contact an CRNS Practice Advisor by phone at 1.800.667.9945 or 306.359.4227 or by email practiceadvice@crns.ca.