Nurse Practitioner STANDARDS OF PRACTICE 2014 COLLEGE OF REGISTERED NURSES OF NOVA SCOTIA

COLLEGE OF REGISTERED NURSES OF NOVA SCOTIA
Nurse Practitioner
STANDARDS OF PRACTICE
2014
Nurse Practitioner Standards of Practice (Effective November 1, 2014)
First Printing (2002)
Revisions (2005/2009/2011/2013)
© 2014, College of Registered Nurses of Nova Scotia
All rights reserved. Individual copies of this document can be downloaded from the College of Registered Nurses of Nova
Scotia website at www.crnns.ca. Print copies can be obtained by contacting the College of Registered Nurses of Nova
Scotia at 902.491.9744 (toll-free in NS 1.800.565.9744), ext. 224/230 or [email protected].
Portions of this publication may be reproduced for individual use. Reproduction of this document for other purposes, by
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TABLE OF CONTENTS
Introduction............................................................................................................................................................... 1
Legislative and Regulatory Basis of Nurse Practitioner Standards of Practice . ........................................................ 1
Profile of the Nurse Practitioner............................................................................................................................... 1
Nurse Practitioner Practice in Nova Scotia ............................................................................................................... 2
Overview of the Standards........................................................................................................................................ 3
Professional Standards
Standard 1: Responsibility and Accountability.......................................................................................................... 3
Standard 2: Leadership and Advocacy....................................................................................................................... 4
Standard 3: Continuing Competence........................................................................................................................ 4
Therapeutic Management Standards
Standard 4: Assessing, Diagnosing and Monitoring ................................................................................................. 5
Standard 5: Prescribing and Monitoring the Therapeutic Treatment Plan . ............................................................. 6
Standard 6: Invasive and Non-Invasive Procedures................................................................................................... 7
Standard 7: Collaboration, Consultation and Referral............................................................................................... 7
Controlled Drugs and Substances Prescribing Standards
Standard 8: Legislative and Regulatory Standards.................................................................................................... 8
Standard 9: Clinical Standards for Prescribing Controlled Drugs and Substances .................................................... 9
Standard 10: Clinical Standards for Prescribing Methadone Maintenance Therapy ................................................ 9
Standard 11: Clinical Standards for Prescribing Methadone for Management of Chronic Non-cancer Pain ......... 10
Operational Definitions........................................................................................................................................... 11
References .............................................................................................................................................................. 14
INTRODUCTION
Purpose of the Nurse Practitioner Standards of Practice
Nurse practitioners work independently and in collaboration with clients and other health professionals to provide
comprehensive health services. The nurse practitioner role carries with it significant responsibility for the health and
well-being of clients. It is, therefore, essential that nurse practitioners adhere to their code of ethics and standards of
practice.
In Nova Scotia, nurse practitioners are required to adhere to both the Standards of Practice for Registered Nurses and the
Nurse Practitioner Standards of Practice. As the regulatory body for the nursing profession in Nova Scotia, the College of
Registered Nurses of Nova Scotia (CRNNS) sets the practice standards for registered nurses and nurse practitioners in the
province.
The nurse practitioner standards of practice outlined in this document reflect the minimum professional practice
performance that the public can expect from any nurse practitioner in any setting or role in Nova Scotia. These standards
outline the professional and legal obligations and responsibilities of nurse practitioners, so that nurse practitioners have
clear guidance in every aspect of their practice. The standards are used as a regulatory benchmark against which nurse
practitioner performance is measured. By ensuring high quality nurse practitioner practice, these standards protect the
health and safety of the public.
The CRNNS reviews and revises the Nurse Practitioner Standards of Practice on a regular basis to ensure that they reflect
the continually changing practice of nurse practitioners. These 2014 standards were developed with input from nurse
practitioners and other provincial/territorial and national stakeholders.
Legislative and Regulatory Basis of Nurse Practitioner Standards of Practice
The Registered Nurses Act (RN Act, 2006) authorizes nurse practitioners to independently perform a range of health
services that extend beyond those of registered nurses. These health services require a high level of autonomy in
decision making and accountability for client care and health outcomes.
The RN Act (2006) and Regulations (2009) outline the professional practice of nurse practitioners and give the CRNNS the
authority to establish, monitor and enforce standards for the practice and education of nurse practitioners.
The CRNNS regulates the practice of nurse practitioners and promotes excellence in the profession to ensure the public
receives safe, competent, ethical and compassionate care. Nurse practitioners are professionally, ethically and legally
accountable to practise according to the practice standards. At the same time, employers have an obligation to provide
support systems and resources that enable nurse practitioners to meet these standards.
In order to maintain their registration in Nova Scotia, nurse practitioners must complete the CRNNS’s annual Continuing
Competence Program (i.e., Building Your Profile™). Additionally, every five years, they must participate in a mandatory
quality assurance practice review through the Nurse Practitioner–Quality Monitoring & Improvement Program (NPQMP)™.
Profile of the Nurse Practitioner
Nurse practitioners are autonomous health professionals with education in advanced nursing practice and theory. As
advanced practice nurses, they provide a comprehensive range of essential health services grounded in professional,
ethical and legal standards, within a holistic model of care. In providing these services, nurse practitioners draw on their
education, practical experience and in-depth knowledge of the biological and psychosocial aspects of health and disease.
They also apply their understanding of health management, health promotion, health protection, disease and injury
prevention, and the determinants of health.
Nurse practitioners work in collaboration with their clients and other healthcare providers to provide high-quality,
person-centred care. They work with diverse client populations in a variety of contexts and practice settings. For
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example, some nurse practitioners provide primary care in family practice settings, while others work in highly
specialized fields in hospitals and clinics. Regardless of where they practise or with whom, nurse practitioners are
accountable for their own practice and for providing leadership to enhance client care and care-delivery systems within
their focus of practice.
Nurse practitioners are educated and licensed to conduct comprehensive health assessments and to diagnose, treat and
manage acute and chronic physical and mental conditions. They identify health risks, order and interpret screening and
diagnostic tests, perform procedures, prescribe medications, and monitor treatment results. At the same time, nurse
practitioners have the expertise, advanced communication skills and professional frame of reference to provide health
and wellness counseling, with an emphasis on prevention and proactive health management.
Communication is at the core of nurse practitioner-client relationships. Nurse practitioners listen thoughtfully to their
clients, learn about their health status, and counsel them on a range of health- and illness-related concerns. This could
include advising clients about how to manage their symptoms or maintain their health through self-care strategies,
medications, or complementary and alternative therapies. Nurse practitioners also communicate clearly with clients
about health assessment findings, diagnoses, further testing that may be required, and potential courses of treatment
and their implications. When necessary, nurse practitioners refer clients to other healthcare professionals, services and
programs.
In their interactions with clients, nurse practitioners support clients’ strengths, capabilities, needs, values, cultures and
choices. They work closely with clients to help them make informed decisions about their health and to develop and
monitor appropriate plans of care.
As they perform these activities, nurse practitioners have a responsibility to consider issues of resource allocation and
the cost-effectiveness of healthcare decisions, in accordance with federal and provincial policy and legislation. They are
also accountable for setting up processes that enable them to effectively receive and track test results, interventions,
referrals, consultations and outcomes. Finally, nurse practitioners are required to collaborate with other healthcare
providers and/or agencies in a timely manner when needed.
In addition to their role in clinical care, nurse practitioners have the knowledge and skills to play a broader role in the
healthcare system and society at large. They are equipped with the expertise to assess population health, evaluate
health outcomes, and develop health policies and health services. Nurse practitioners also provide leadership to multistakeholder efforts to design, implement and evaluate strategies aimed at promoting health and preventing illness
and injury. They pursue these goals in collaboration with other healthcare providers and community members in the
healthcare sector, as well as in non-healthcare sectors such as education and law enforcement.
Nurse Practitioner Practice in Nova Scotia
In Nova Scotia, the practice of a nurse practitioner is defined in the RN Act (2006):
Practice of a nurse practitioner means the application of advanced nursing knowledge, skills and judgment in addition to
the practice of nursing in which a nurse practitioner in collaborative practice may, in accordance with standards for nurse
practitioners, do one or more of the following:
(i) make a diagnosis identifying a disease, disorder or condition,
(ii) communicate the diagnosis to the client and health care professionals as appropriate,
(iii) perform procedures,
(iv) initiate, order or prescribe consultations, referrals and other acts,
(v) order and interpret screening and diagnostic tests, and recommend, prescribe or reorder drugs, blood, blood
products and related paraphernalia,
and also includes research, education, consultation, management, administration, regulation, policy or system
development relevant to sub clauses (i) to (v).
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In order to practise as nurse practitioners in Nova Scotia, nurse practitioners must have a collaborative practice
relationship with a physician or a group of physicians. The purpose of this collaborative relationship is to ensure that a
physician has agreed to be available for collaboration, consultation and referral when needed.
Overview of the Standards
The standards of practice in this document are authoritative statements that set out the legal and professional basis for
nurse practitioner practice in Nova Scotia. The CRNNS has developed this document, along with the Nurse Practitioner
Competency Framework (2011), to direct, evaluate and regulate nurse practitioner practice. These documents also serve
to inform the public as to what they can expect from nurse practitioners.
This document separates the nurse practitioner standards of practice into three categories: professional standards,
therapeutic management standards and controlled drugs and substance prescribing standards. The nurse practitioner
professional standards address: responsibility and accountability; leadership and advocacy; and continuing competence.
The therapeutic management standards address: assessing, diagnosing and monitoring; prescribing; performing invasive
and non-invasive procedures; and collaborating, consulting and referring.
The controlled drugs and substances (CDS) prescribing standards address the legislative and regulatory standards as
well as the clinical standards that apply specifically to these pharmaceutical agents. The CDS Standards are used in
conjunction with the established Professional Standards and Therapeutic Management Standards. The nurse practitioner
is expected to integrate all pertinent standards when prescribing controlled drugs and substances.
The clinical standards relating to prescribing Methadone Maintenance Therapy (MMT) for managing addictions and/or
chronic non-cancer pain apply to those nurse practitioners who have developed their scope of practice to include these
therapies in their scope of practice.
PROFESSIONAL STANDARDS
Standard 1: Responsibility and Accountability
Nurse practitioners are responsible and accountable for providing competent, safe and ethical care within their legislated
scope of practice. In terms of specific functions, nurse practitioners are responsible and accountable for assessing,
diagnosing, treating, managing, monitoring and evaluating clients’ health conditions. They perform these functions in
accordance with their educational preparation, competence and focus of practice.
Nurse practitioners:
1.1 Practise according to ethical, legislative and professional standards that reflect their increased level of
responsibility, accountability and scope of practice.
1.2 Notify the CRNNS when considering changing their patient population and/or practice setting and, as
required, successfully complete the CRNNS’s Competence Assessment Program for nurse practitioners.
1.3 Provide only those health services that legislation, standards or policies grant them authority to
perform and for which competence has been achieved and maintained. The only exception is in
life-threatening emergency situations. In such situations, nurse practitioners are ethically obliged to
provide the best care they can within the constraints of the circumstances.
1.4 Base treatment decisions on the best evidence that appropriate sources can provide, as well as their
own clinical judgment and their clients’ needs, while considering client preferences.
1.5 Practise autonomously and collaboratively as a member of an interprofessional team.
1.6 Document all aspects of client care as required by legislation/regulation (federal/provincial/territorial)
and policy (CRNNS and employer).
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1.7 Maintain, store and transfer client health records according to legislation/regulation (federal/
provincial/territorial), professional standards and relevant policies.
1.8 Arrange for another professional(s) to provide care for clients who need urgent, continuous and/or
follow-up care during times when the nurse practitioner will be absent.
1.9 Recognize and address situations that place them in a conflict of interest, and take steps to avoid any
actions or situations that could put them in a conflict of interest.
1.10 Recognize and address breaches of legal, ethical and practice standards, made by themselves or by
others, in a timely and appropriate manner.
Standard 2: Leadership and Advocacy
Nurse practitioners have a leadership role in the healthcare system. They work collaboratively with other healthcare
professionals and policymakers to influence policy decisions that affect health services and the allocation of resources.
They advocate for their clients’ needs within the healthcare system. Through their leadership, nurse practitioners
enhance the quality of client care and improve the delivery of health services within their focus of practice.
Nurse practitioners:
2.1 Identify, implement and evaluate strategies to improve healthcare services and resulting health
outcomes for the clients and communities they serve.
2.2 Work with communities and other healthcare professionals and stakeholders to identify and advocate
for health services and resources that are needed in the communities they serve.
2.3 Develop, implement and evaluate targeted health promotion and injury prevention activities for
individuals, families, communities—and specific age and cultural groups—as appropriate to their focus
of practice.
2.4 Contribute to the development of standards, practice guidelines and policies related to nurse
practitioner practice.
2.5 Identify policies and procedures that need to be created or revised to improve client care, and take
part in developing and/or revising these policies and procedures.
2.6 Contribute to evidence-based practice by participating in research, sharing information, and educating
peers, other health professionals, clients and communities.
2.7 Educate the public, employers and other health providers about the role of nurse practitioners, and
share evidence of nurse practitioners’ contributions to improving health services and client outcomes.
2.8 Act as role models and mentors to registered nurses, other nurse practitioners, students and other
health professionals within the healthcare team.
Standard 3: Continuing Competence
Nurse practitioners are responsible for maintaining and enhancing all of their current competencies. At the same time,
they must continue to develop new competencies that are relevant to the scope and context of their practice and equip
them to serve their particular client population better.
Nurse practitioners:
3.1 Pursue and complete continuing education appropriate to their focus of practice.
3.2 Acquire theoretical knowledge of new skills and procedures and practise under qualified clinical
supervision before performing them independently.
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3.3 Demonstrate up-to-date knowledge and the ability to critically appraise information about therapies,
best practices, guidelines and resources pertaining to their focus of practice.
3.4 Participate in the CRNNS’s Continuing Competence Program (Building Your Profile™). This involves
an annual process of reflecting on their own practice, seeking feedback from other members of the
healthcare team, determining their own learning needs, developing and achieving learning objectives,
and keeping a record of their efforts to build their competence.
3.5 Propose and negotiate opportunities to enhance their knowledge and skills.
3.6 Fulfill the requirements of the Nurse Practitioner–Quality Monitoring & Improvement Program™ and
take the initiative to improve their practice based on their results.
THERAPEUTIC MANAGEMENT STANDARDS
Standard 4: Assessing, Diagnosing and Monitoring
Nurse practitioners assess, diagnose, treat and monitor clients with acute and chronic physical and mental health
conditions, using a variety of techniques, tools and sources of information. In providing this care, nurse practitioners
take a person-centred approach that engages clients in identifying their health needs, understanding their options and
making choices about their health. Nurse practitioners’ therapeutic management is informed and guided by the best
available evidence and an understanding of the holistic nature of health and social determinants of health.
Nurse practitioners:
4.1 Perform comprehensive or focused assessments that are appropriate to a client’s situation. This can
include taking a history, performing a physical examination and/or reviewing reports of other health
professionals’ assessments, investigations and findings.
4.2 Determine clients’ health risks and differential diagnoses, based on the findings of their assessments,
to guide them in their decisions regarding further investigations, ongoing monitoring, and
consultations with other professionals.
4.3 Select screening, diagnostic and monitoring tests based on best-available evidence, best practice
guidelines, and provincial and organizational policies and standards. This includes considering the risks,
benefits, appropriateness and cost-effectiveness of potential tests.
4.4 Discuss with clients the purpose and risks of screening and diagnostic tests, and why the findings might
be important to that person’s health.
4.5 Order and interpret diagnostic tests, according to the Nurse Practitioners’ Authorized Practices: Nova
Scotia Schedule of Screening and Diagnostic Tests, to identify and monitor client health risks, and to
diagnose and monitor acute or chronic physical or mental health conditions.
4.6 Establish a systematic and timely process to receive, document, track and communicate test results.
4.7 Formulate definitive and working diagnoses and consider their potential implications, treatment plans
and expected outcomes/prognoses, based on the overall health status of clients.
4.8 Communicate diagnoses, potential implications, treatment plans, expected outcomes and overall
prognoses in a sensitive, honest and respectful manner that anticipates and responds to clients’
feelings and concerns.
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Standard 5: Prescribing and Monitoring the Therapeutic Treatment Plan
Nurse practitioners are responsible for prescribing safe, effective and appropriate pharmacological and nonpharmacological therapy when assessments, investigations and clients’ situations indicate that therapy is desirable or
necessary. These therapies include pharmaceuticals, blood/blood products, medical gases, alternative therapies, health
programs and services, and related healthcare equipment/supplies for clients with acute and chronic health conditions.
Nurse practitioners actively engage clients in the process of deciding what therapeutic options to pursue in their
situations, and respect their clients’ choices about therapies.
Nurse practitioners:
5.1 Prescribe medications according to ethical and professional standards, federal/provincial/territorial
legislation, regulations and policies, and organizational policies.
5.2 Prescribe medications according to the Nurse Practitioners’ Authorized Practices: Nova Scotia Schedule
of Prescribing Pharmaceuticals and considering financial implications to the client in the context of the
current public and private third-party insurers’ reimbursement parameters.
5.3 Prescribe and monitor pharmacological and non-pharmacological therapies according to research
evidence and the most up-to-date guidelines for best clinical practice.
5.4 Evaluate the evidence for the therapeutic benefit and cost-effectiveness of pharmacological and/or
non-pharmacological therapies.
5.5 Examine marketing strategies used to promote health products, medical devices, medications,
alternative therapies and health programs, and consider their potential influence on prescribing
patterns.
5.6 Counsel clients on prescription and non-prescription drugs and cost-effective alternatives, including
rationale, expected effect, potential side/adverse effects, interactions with other substances,
precautions specific to the drug or clients, reasons to adhere to the prescribed regimen (dose,
frequency, duration), and required follow-up.
5.7 Monitor clients’ responses to drug therapies and continue, adjust, or discontinue a drug based on their
observations of these responses.
5.8 Complete prescriptions, in writing or otherwise, according to the Nova Scotia Practice of Pharmacy
Regulations (2003) and other relevant legislation, standards and policies.
5.9 Discuss potential benefits and risks of alternative or complementary therapies with clients as
appropriate.
5.10 Document the rationale for pharmacological and non-pharmacological therapies and expected
treatment outcomes.
5.11 Document and report adverse events associated with pharmacological and non-pharmacological
therapies according to federal/provincial/territorial legislation, regulation and policy, and
organizational policy (e.g., Canadian Adverse Drug Reaction Reporting Program).
5.12 Refrain from prescribing pharmacological therapy for themselves or family members, except to
intervene in an emergency situation or to treat a minor/episodic condition when there is no other
prescriber available.
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Standard 6: Invasive and Non-Invasive Procedures
Nurse practitioners are responsible and accountable for performing both non-invasive and invasive procedures for which
they have developed and maintained competence. Nurse practitioners perform these procedures in a safe, competent
and ethical manner in order to assess, restore or maintain client health.
Nurse practitioners:
6.1 Perform non-invasive and invasive procedures in accordance with the Nurse Practitioners’ Authorized
Practices: Nova Scotia Schedule of Procedures.
6.2 Communicate the evidence-informed rationale for proposed invasive and non-invasive procedures,
so that clients can make informed decisions; taking into account clients’ needs and circumstances,
expected therapeutic effects, contraindications, risks, precautions and required follow-up.
6.3 Obtain and document clients’ informed consent (verbal and/or written) prior to performing
procedures, when required.
6.4 Anticipate and safely manage potential unintended procedural outcomes.
6.5 Monitor, evaluate and document clients’ responses to and outcomes of procedures.
Standard 7: Collaboration, Consultation and Referral
Nurse practitioners collaborate, consult with and refer clients to the most appropriate health professional when they
determine that another professional’s expertise is required for competent and safe client care. Prior to acting on advice
from other health professionals, nurse practitioners are required to evaluate these recommendations in light of a
client’s current situation and healthcare preferences. In addition, nurse practitioners accept referrals and requests for
consultation from other healthcare providers and are accountable for the advice and recommendations they provide.
Consultations may occur in person, by telephone, in writing or electronically, as appropriate to individual situations.
Nurse practitioners:
7.1 Establish a collaborative practice relationship with a physician or group of physicians based on the
Guidelines for Collaborative Practice Teams and Employers of Nurse Practitioners. They submit a
Collaborative Practice Relationship Verification Form when entering or leaving a practice and when
changing collaborating physicians or client populations.
7.2 Establish collaborative relationships and networks with other healthcare providers and organizations,
as appropriate to the nurse practitioner’s focus of practice.
7.3 Recognize the need for consultation and/or referral and initiate requests in a timely manner when the
expertise of another health professional or agency is required for safe and effective client care.
7.4 Discuss the nature, rationale and expected outcomes of proposed consultations and referrals with
clients.
7.5 Approach the most appropriate healthcare professional(s) for consultation or referral when a client’s
care requirements exceed the nurse practitioner’s competence or scope of practice.
7.6 Consult with and/or refer to a physician when a client’s health condition is unstable or likely to
destabilize/deteriorate, or when signs, symptoms and/or diagnostic tests suggest a systemic infection,
vital-organ obstruction, and/or potential threat to life, limb or senses.
7.7 Communicate and document the reason, level of urgency and expected action from consultants (e.g.,
opinion, recommendation, shared care, transfer of care) when requesting a consultation or referral.
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7.8 Evaluate advice and recommended treatment plans from other healthcare professionals, including
consultants, and discuss the recommendations with clients.
7.9 Accept referrals and requests for consultation from other healthcare providers and provide advice and
recommendations based on their knowledge, individual competence and focus of practice.
7.10 Clearly communicate and document the advice and recommendations they provide when responding
to requests for consultations or referrals.
CONTROLLED DRUGS AND SUBSTANCES PRESCRIBING STANDARDS
In November 2012, the New Classes of Practitioners Regulations (NCPR) under Canada’s Controlled Drug and Substances
Act (CDSA) came into force. This change at the federal level expands the prescriptive authority of nurse practitioners to
include medications, with some exceptions, that fall under the CDSA. In Nova Scotia, the CRNNS is responsible for the
development, implementation, enforcement, and evaluation of regulations, standards and competencies to guide nurse
practitioner prescribing under the NCPR. The nurse practitioner Controlled Drugs and Substances Prescribing Standards
have been developed in consultation with government, the College of Physicians and Surgeons of Nova Scotia, the Nova
Scotia College of Pharmacists, employers, universities, and practicing nurse practitioners.
The Controlled Drugs and Substances Prescribing Standards outlined in this section are intended to specifically define
the nurse practitioner’s professional and legal obligations related to the safe prescribing of medications that fall under
the CDSA. As with all standards in this document, the CDS Prescribing Standards are used as regulatory benchmarks
against which nurse practitioner performance is measured. The CDS Prescribing Standards also support other provincially
legislated programs relating to CDS prescribing (e.g. Prescription Monitoring Program) currently in place in Nova Scotia to
provide safe client care.
Standard 8: Legislative and Regulatory Standards
Nurse practitioners are knowledgeable about the federal and provincial legislation and regulations relating to the
management of controlled drugs and substances. The following legislative and regulatory standards apply to prescribing
for all controlled drugs and substances.
Nurse practitioners:
8.1 Prescribe controlled drugs and substances according to relevant legislation, standards and policies
8.2 Complete prescriptions for controlled drugs and substances in the form approved by the Prescription
Monitoring Program Board, and in accordance with the Nova Scotia Pharmacy Act and Regulations,
the Prescription Monitoring Program Act and Regulations and other relevant legislation, standards and
policies.1
8.3 Adhere to guidelines regarding safe storage and transportation of controlled drugs and substances if
required in their focus of practice.
8.4 Complete initial Controlled Drugs and Substance education requirements as set out by the CRNNS.
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Legislation and policy related to the prescribing of controlled drugs and substance include but are not limited to: the Controlled Drugs
and Substances Act, Food and Drug Regulations, Narcotic Control Regulations, Benzodiazepines and Other Targeted Substances Regulations, Nova
Scotia Pharmacy Act and Regulations, Nova Scotia Prescription Monitoring Program Act and Regulations and the Nova Scotia Nurse PractitionerAuthorized Practice Schedule – Pharmaceuticals.
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Standard 9: Clinical Standards for Prescribing Controlled Drugs and Substances
Nurse practitioners are responsible for prescribing controlled drugs and substances in a safe and effective manner when
assessments, investigations and diagnoses indicate that this therapy is appropriate. In addition, nurse practitioners
actively counsel their clients regarding safety of controlled substances; taking into account their client’s personal
situation and social determinants of health. Controlled drugs and substances include agents listed under the Controlled
Drugs and Substances Act.
Nurse practitioners:
9.1 Prescribe controlled drugs and substances based on evidence, best practice and current clinical
practice guidelines appropriate to the NP’s focus of practice.
9.2 Complete a comprehensive assessment of the client’s diagnoses, history of previous controlled
drugs and substance use verified through PMPs E-access patient profile portal, comorbid conditions,
prescribed medications (both controlled drugs and substances and other medications), other nonpharmacological therapies, psychosocial, psychiatric and substance use history, and risk assessment for
addictive behaviours.
9.3 Develop a holistic and individualized plan of care in conjunction with the client and other health care
team members.
9.4 Negotiate, document and communicate a treatment agreement with the client and other designated
prescribing providers; and register the treatment agreement with the Nova Scotia Prescription
Monitoring Program when indicated.
9.5 Monitor clients’ response to prescribed controlled drugs and substances after initial trial and on a
regular basis, using evidence-informed assessment tools.
9.6 Revise the plan of care by continuing, adjusting, weaning or discontinuing the prescribed controlled
drugs and substances; based on client’s therapeutic response, expected treatment outcomes,
adherence to treatment plan, aberrant drug behavior, current evidence, and potential for misuse or
diversion.
9.7 Maintains knowledge of current evidence and best practice related to prescribing of controlled drugs
and substances.
9.8 Collaborate with the health care team and other stakeholders in the development and evaluation of
controlled drugs and substances prescribing practices within focus of practice; considering their impact
at the individual, family, and community level.
9.9 Collaborate in the development of safety measures for prescribers and other staff to address increased
risks associated with prescribing controlled drugs and substances, including methods to provide for a
safe working environment.
Standard 10: Clinical Standards for Prescribing Methadone Maintenance Therapy
Nurse practitioners with an exemption from Health Canada - Office of Controlled Substances, Methadone Programme are
responsible to prescribe Methadone Maintenance Therapy (MMT) for managing clients with opiate addictions in a safe
and effective manner.
Nurse practitioners:
10.1 Complete the Centre for Addictions and Mental Health (CAMH) Opioid Dependence Treatment Core
Course for opioid dependency (or equivalent course at the discretion of the CRNNS) prior to applying
for a methadone exemption.
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10.2 Complete the minimum equivalent of one day of clinical training with a physician who holds an
exemption for Methadone Maintenance Therapy.
10.3 Obtain and maintain an exemption for Methadone Maintenance Therapy for opioid dependency from
Health Canada Office of Controlled Substances, Methadone Programme and issued by the CRNNS.
10.4 Prescribe Methadone Maintenance Therapy, when indicated, according to evidence and guidelines
contained in the current version of the College of Physicians and Surgeons of Nova Scotia (CPSNS)
Methadone Maintenance Treatment Handbook.
Standard 11: Clinical Standards for Prescribing Methadone for Management of Chronic
Non-Cancer Pain
Nurse practitioners with an exemption under section 56 of the Controlled Drugs and Substances Act are responsible to
prescribe Methadone for managing clients with chronic non-cancer pain in a safe and effective manner.
Nurse practitioners:
11.1 Review the most current guidelines for utilizing methadone for management of chronic non-cancer
pain and reflect on implications for focus of practice.
11.2 Complete the minimum equivalent of one day of clinical training with a physician who holds an
exemption and experience in Methadone use for pain management.
11.3 Obtain and maintain an exemption license for Methadone for analgesia from Health Canada Office of
Controlled Substances, Methadone Programme and issued by the CRNNS.
11.4 Prescribe Methadone for chronic non-cancer pain, when indicated, according to current evidence and
guidelines.
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OPERATIONAL DEFINITIONS
Accountability: the obligation to acknowledge the professional, ethical and legal aspects of one’s role, and to answer for
the consequences and outcomes of one’s actions. Accountability resides in a role and can never be shared or delegated.
Advanced nursing practice: an umbrella term describing an advanced level of clinical nursing practice that maximizes
the use of graduate educational preparation, in-depth nursing knowledge, and expertise in meeting the health needs
of individuals, families, groups, communities and populations. It involves analyzing and synthesizing knowledge;
understanding, interpreting and applying nursing theory and research; and developing and advancing nursing knowledge
and the profession as a whole (CNA, 2008a).
Adverse event: an activity/intervention that results in unintended harm to a client, and is related to the care and/or
service provided rather than to the client’s underlying condition (CPSI, 2008).
Advocate: actively supporting a right and good cause, supporting others in speaking for themselves, or speaking on
behalf of those who cannot speak for themselves (CNA, 2008b).
Alternative therapy: form of treatment that is an alternative to conventional therapies; not recognized as mainstream
care, tends to have unproven mechanisms and unconventional evidence (Complementary and Alternative Therapies: A
Guide for Registered Nurses, 2005).
Client(s): the individual, group, community or population who is the recipient of nursing services and, where the context
requires, includes a substitute decision-maker for the recipient of nursing services (RN Act, 2006).
Collaborate: building consensus and working together on common goals, processes and outcomes (CNA, 2008b).
Collaboration: with clients as key members of the healthcare team, nurse practitioners and other healthcare providers
use their separate and shared knowledge and skills in communication and decision making to provide optimum personcentred care, while respecting the unique qualities and abilities of each team member.
Collaborative practice: the relationship among a nurse practitioner, a physician or group of physicians, an employing
organization and other relevant health professionals that enables these healthcare providers to work together – using
their separate and shared knowledge and skills - to provide optimum person-centered care in accordance with standards
of practice for nurse practitioners and guidelines for collaborative practice teams and employers of nurses practitioners
approved by the CRNNS (RN Act, 2006).
Competence: the ability to integrate and apply the knowledge, skills, abilities and judgment required to practise safely
and ethically with a designated client population in a specific nurse practitioner role and practice setting (RN Act, 2006).
Competence Assessment Program: the regulatory mechanism used by the CRNNS to ensure nurse practitioners have
the required education and competence for licensure to practise with their client populations and within their practice
settings.
Competencies: the specific knowledge, skills, abilities, and judgment required for a nurse practitioner to practise safely
and ethically with a designated client population in a specific role and practice setting.
Complementary therapies: health modalities or interventions that tend to be used alongside conventional healthcare
services.
Condition(s): a broad term that includes illness, disease, injury and other health concerns (physical and mental health
issues).
Conflict of interest: when nurse practitioners’ personal interests could improperly influence their professional judgment
or interfere with their duty to act in the best interest of clients.
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Consultation: a request for another health professional’s advice on the care of a client. The goal is to enhance patient
care and/or improve the skills and confidence of the professional making the request (i.e., consultee). The consultant
may or may not see the patient directly. The responsibility for clinical outcomes remains with the consultee, who is free
to accept or reject the advice of the consultant (Barron & White, 2009, p. 194).
Determinants of health: range of social, economic, geographic and systemic factors that influence a person’s health
status and outcomes. These factors include: access to appropriate health services, biology, coping abilities, culture,
education, employment and working conditions, environment (natural and built, emotional and psychological), gender,
genetics, health behaviours, income, lifestyle, and social status.
Differential diagnosis: process of weighing the probability that one disease versus other diseases is responsible for a
client’s illness.
Disease and injury prevention: measures taken to prevent the occurrence of disease and injury (e.g., risk-factor
reduction) and to arrest the progress and reduce the consequences of disease or injury.
Emergency situation: sudden onset of severe or urgent symptoms that require immediate attention such that a delay in
treatment would place an individual at risk of serious harm.
Focus of practice: nurse practitioner’s client population (family, all ages, adult, child, neonate), area of specialty (e.g.,
primary healthcare, women’s health, nephrology, cardiology, gerontology) and practice setting (e.g., community care,
primary care, acute care, emergency care, long-term care).
Health: state of complete physical, mental, spiritual and social well-being, and not merely the absence of disease (WHO,
1946).
Health management: range of activities required to care for a person’s health including assessment and diagnosis,
therapeutic management, monitoring, follow-up and evaluation.
Health promotion: process of enabling people to increase control over and improve their health. It embraces actions
directed not only at strengthening the skills, confidence and capabilities of individuals, but also at changing social,
environmental, political and economic conditions to alleviate their impact on public and individual health.
Health protection: activities in food hygiene, water purification, environmental sanitation, medication safety, and other
areas designed to eliminate or minimize the risk of adverse consequences to health.
Holistic model of care: an approach to health care that incorporates all aspects of clients’ physical, psychological,
emotional, spiritual, and social needs in the provision of care.
Minor/episodic condition: short-term, acute, non-urgent illness that requires short-term treatment and is not likely to
indicate or lead to a more serious condition. Examples include a nonrecurring urinary tract infection or a non-recurring
upper respiratory tract infection in an otherwise healthy individual.
Order: request that a procedure, treatment, medication, intervention or referral be provided to a client: can be in the
form of a prescription or requisition, verbal (e.g., during an emergency) or transmitted by telephone (i.e., when the nurse
practitioner is not physically present).
Person-centred care: a process that places a person at the centre of the collaborative healthcare team and supports that
person’s strengths, capabilities, needs, values, culture and choices. “Persons” are defined as the individuals/families/
friends and communities that are the focus of the health system.
Population health: the health of populations and the factors that influence health and health risks.
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Prescribe: to advise or authorize the use of a medication or treatment for the management of a client’s diagnosis
or diagnoses. The act of prescribing involves assessment and monitoring the safety and efficacy of the prescribed
medication or treatment.
Referral: an explicit request for another health professional to become involved in the care of a client. “The goal of
referral is to enhance patient care by relinquishing care, or aspects of care, to another professional whose expertise is
perceived to be more essential to the patient’s care than that of the professional making the referral. The focus is on
establishing a connection between a patient and the professional who is accepting the referral and to negotiate which
professional (i.e., the professional making the referral or the professional receiving the referral) will be responsible for
what outcomes. The responsibility for clinical outcomes is negotiated but responsibility is often assumed (at least for
aspects of care) by the professional accepting the referral.” (Barron & White, 2009, p. 194)
Responsibility: an activity, behaviour or intervention expected or required to be performed within a professional role
and/or position: may be shared, delegated or assigned.
Safe client care: an approach to care that reduces or mitigates unsafe acts or situations by using evidence-informed and/
or best practices shown to lead to optimal client outcomes.
Scope of practice: the roles, functions, and accountabilities that nurse practitioners are educated and authorized to
perform, as established through legislated definitions of nurse practitioner practice and complemented by standards,
guidelines and policy positions issued by professional nursing bodies.
Standards: authoritative statements that promote, guide, direct and regulate professional nursing practice: describe the
desirable and achievable level of performance expected of all registered nurses, including nurse practitioners, against
which actual performance can be measured.
Therapeutic management: the pharmaceuticals, non-pharmaceuticals, therapies and interventions that nurse
practitioners prescribe to promote and protect health, prevent disease, and treat diseases, injuries, illnesses and
conditions.
Treatment agreement: a written contract between the client and provider(s) designated as primary prescribers of
controlled drugs and substances for the patient which acknowledges the responsibilities and outlines the commitment
of both parties to the plan of care. The agreement may include terms of treatment (e.g. appointments, refill limits,
designated providers), prohibited behaviours and reasons for termination of the contract (e.g. misuse or diversion
activities, missed appointments, violation of the terms of the agreement or other inappropriate behaviour).
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Newfoundland and Labrador. St. Johns, NL: Author.
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integrative approach (pp. 191-216). St. Louis: Saunders Elsevier.
Canadian Nurses Association. (2008a). Advanced nursing practice: A national framework. Ottawa, ON: Author.
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of Nova Scotia. Retrieved from https://www.novascotia.ca/JUST/REGULATIONS/regs/pharmprc.htm
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en/print.html
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