The Ontario provincial government has said it will expand the scope of practice of registered nurses (RNs) in Ontario to allow them to prescribe medications. Currently, only doctors and nurse practitioners have the ability to prescribe medications. This is a move that could radically change health care – some say for the better, but others are concerned.
The main impetus for the increased scope of practice is that allowing RNs to prescribe medications could dramatically improve access to care for some – like people in rural and remote areas who have limited access to nurse practitioners (NPs) and physicians. It can also enable NPs and physicians in busy clinics and hospitals to focus on patients with the most complex conditions, while RNs diagnose and prescribe medications to treat some of the more straightforward reasons people seek health care, like routine vaccinations for healthy babies.
“If RNs could write scripts for patients with simple issues – a urinary tract infection, for example – many patients wouldn’t even have to see a doctor,” argues Doris Grinspun, chief executive officer of the Registered Nurses Association of Ontario (RNAO). “NPs and doctors would have more time to deal with the less run-of-the-mill cases. It would unlock the system,” she says.
But not everyone is convinced that RN prescribing is necessary in the first place, and some worry if RNs are allowed to prescribe without supervision, it will jeopardize patient safety.
In order to learn more about the benefits and challenges of RN prescribing, Ontario’s Minister of Health and Long-Term Care has asked the Health Professions Regulatory Advisory Council (HPRAC) to investigate and make recommendations to the Province about RN prescribing. The Council has been tasked with figuring out which of the three different models for RN prescribing is best for Ontario. They are to evaluate the models on various criteria, including whether the form of RN prescribing would fill a public need and how easily the risks of each model could be mitigated.
Models for RN prescribing
The model of RN prescribing that is the most different to the status quo is independent prescribing, where RNs would be able to diagnose certain conditions and prescribe the most appropriate medications to treat those conditions – either from a pre-defined list of medications or based on a specific area of medicine.
In this model, RNs who work in a travel clinic, for example, would be enabled to prescribe some vaccinations. RNs who work in long-term care, meanwhile, might be allowed to diagnose and treat a urinary tract infection in elderly clients.
Independent prescribing by RNs is not a completely new concept. In British Columbia, RNs who meet requirements including the completion of an online course can independently prescribe drugs including medications to treat sexually transmitted infections, vaccines for travelers as well as a limited number of other special-case scenarios. Newfoundland and Labrador and many other provinces are considering or currently implementing RN independent prescribing for specific medications and situations. Internationally, various forms of independent prescribing are in place in Ireland, New Zeland, the UK and some US states.
The second model is protocol-based prescribing, in which RNs could prescribe, but only following a protocol developed by a team of medical professionals. The protocol might instruct the RN on what tests to order, what questions to ask and what dose to provide under what circumstances. As Grinspun points out, this model is, practically speaking, the same as what is already in Ontario and in most provinces in the country. Currently in Ontario, RNs can prescribe under protocols, which are known as standing orders or medical directives and have been developed by a doctor or medical team within their organization.
The third model is supplementary prescribing. In this model, a NP or physician comes up with a plan for a specific patient, and the RN may prescribe according to that patient’s plan.
The evidence behind any of the models is limited. A preliminary review conducted by HPRAC looked at RN prescribing in other countries and found that, overall, there were no major differences in the appropriateness or safety or prescriptions made by nurses versus doctors – whether nurses were prescribing in an independent, protocol-based or supplementary way. But the studies were few and the methods open to bias. (As RN prescribing is new in British Columbia, HPRAC wasn’t able to find evidence of RN prescribing effectiveness here.) Plus, it’s hard to compare RN prescribing in one country to another, given each jurisdiction has different processes and education requirements for RN prescribing.
Arguments for independent versus protocol-based RN prescribing
Because the debate among stakeholders centres around independent versus protocol-based prescribing, we will focus on these models.
Adriana Tetley, chief executive officer of the Association of Ontario Health Centres, says that independent RN prescribing would save patients time as well as be cost saving, because patients would see one professional instead of two. “Right now, patients will see the nurse, the nurse can do the assessment, and they know they have a common infection, but they have to now be seen by another provider – either a nurse practitioner or a physician to get that prescription,” says Tetley, who represents community-governed primary health centres.
The move would be a huge help to marginalized populations as well, argues Kim Cook, a RN and vice president of community health and chief of professional practice at Scarborough Centre for Healthy Communities. For RNs who do outreach work in sexual health clinics or homeless shelters, they may meet a patient who clearly has a treatable infection, but they miss the opportunity to treat it because they have to refer the patient to see a doctor. “They’re on the street and you may never see them again,” says Cook.
Nancy Lefebre, chief clinical executive at Saint Elizabeth, which provides home care services across Canada, also sees RN prescribing as being a win for patients who are visited by nurses at home. “Home care is a 24-7 kind of service and people live in remote and rural locations so it’s not always easy to access someone who can prescribe,” she says.
Tetley and Cook explain that protocol-based prescribing won’t suffice because many organizations don’t go to the trouble of developing protocols – they take professionals’ time and therefore money to produce and need to be frequently updated, explains Grinspun. For this reason, as Cook says, “There are a very limited number of protocols.”
On the other side of the argument are groups like the Ontario Medical Association and the Nurse Practitioners Association of Ontario.
Theresa Agnew, president of the Nurse Practitioners Association of Ontario, thinks that protocol-based prescribing is the way to go, and that protocols should be increased. “If RNs want to [independently] prescribe, they should become nurse practitioners,” she says. “We already have the evidence to show that nurse practitioner prescribing is safe. And we have the education models and quality control in place. Why reinvent the wheel?”
RNs can take a NP course after three years of working as an RN (on average, however, most wait 16 years, according to Agnew). To become a NP, a RN must take a 24-month course that includes 750 hours of training in a clinical setting. The 300-hour course that the RNAO is proposing for RNs who wish to prescribe isn’t adequate enough,” says Agnew.
Michael Toth, president of the Ontario Medical Association also seems to suggest that only doctors and NPs should independently prescribe. “Currently, [NPs] have specialized training that allows them to independently prescribe medications. They can do this because they possess graduate level training that includes advanced health assessment…caution should be exercised in deciding whether or not a group of practitioners should be able to independently prescribe,” wrote Toth in a statement to Healthy Debate.
But Lefebre says there are not enough NP training centres. “We don’t graduate enough NPs to meet the need,” says Lefebre. “And while intensive training makes sense for NPs, who can diagnose and treat a wide range of conditions, RNs would prescribe in limited circumstances, for some of the most common conditions they see.”
Agnew isn’t comforted by the idea that if independent prescribing was pursued, RNs would only prescribe within their scope – for conditions in which they feel they have the training and experience to prescribe. “You don’t know what you don’t know,” she argues. What looks like a simple urinary tract infection could in rare cases be something more serious – and RNs don’t have the training to always know when to consider the rare, other possible causes, says Agnew.
Allan Malek, senior vice president of professional Affairs at the Ontario Pharmacist Association is also concerned that the idea RN can independently prescribe to treat ‘simple’ conditions is too simplistic. “When it comes to prescribing, it’s not really a simple algorithm, saying this is the condition, this is the drug for that condition and away we go,” he says. “Do they know how to appropriately assess the individual, do they know what the various medical conditions are that may be underlying their symptoms, do they know about the other the medications they take and the interactions?” (While Malek isn’t completely against the idea of RNs prescribing, he says that prescribing skills should be taught and examined to ensure that all of the issues that “wrap around” a prescription are well understood.)
To Lefebre, the fear that RNs might not safely prescribe without protocols in place doesn’t hold water. She points out that in northern communities, RNs are already making decisions on which patients may need to be flown to another location for emergency care, for example. “They’re assessing, they’re making critical diagnoses,” she says. “It doesn’t make sense that nurses can make major decisions in one area, but they can’t do it in another area.”
And the suggestion that nurses could unwittingly prescribe outside of their knowledge base is also unfounded, RN prescribing proponents argue. Grinspun points out that “any health provider, including doctors can do more than what they know.” Just like doctors, adds Cook, RNs are regulated by a College, which requires them to “do self-reflection” in regards to their knowledge and skills and ensure they meet the skills they require are up to date via continuing education. And it’s not just the individual – supervisors at workplaces would also decide which conditions a RN would be able to treat, based on the persons’ skills and training, Cook explains.
Are RN prescribers really needed?
Barbara Mildon, chief nursing executive at Ontario Shores Centre for Mental Health Sciences, takes a third position: RN independent prescribing makes sense for a limited range of settings and sectors but shouldn’t happen everywhere.
Mildon doesn’t think for example, that there is benefit to RNs prescribing in in-patient settings where physicians and nurse practitioners are available. Mildon also worries about patient safety if there are multiple people prescribing for the same patient: “if providers don’t know all of the medications a patient is already taking there is a potential for duplication of medication or for adverse reactions if new medications are added,” explains Mildon. (That said, even if independent RN prescribing was made legal by the Ontario government, hospital managers would be able to decide if RNs could take on prescribing roles at their institution, and whether RN prescribing is done in a protocol-based or independent way.)
Agnew added that RN prescribing could add to a problem health care is facing – that of too many prescriptions. “I sit on five different committees that are looking at the negative effects of polypharmacy,” says Agnew, referring to the fact that currently, too many Ontarians are taking multiple different medications, some of which are unnecessary.
But unlike Agnew, Mildon thinks that independent RN prescribing, if circumscribed, will be beneficial. In BC, she explains, nurses in sexual health clinics have a list of medications they can prescribe, including contraception and antibiotics for sexually transmitted infections. “They learn, ‘This is what these medications do, these are the indications to prescribe them, this is how you’re going to teach the patient about how to take them, this is what to watch for in terms of good outcomes,” she explains. (RNs would also need to know what kind of co-existing medical conditions to ask about before a certain drug is given, if the drug could exacerbate other conditions). Likewise, in remote or rural health centres, RNs could prescribe from a limited list of drugs. “If a patient has all the signs of a urinary tract or wound infection, RNs being able to prescribe antibiotics makes perfect sense,” says Mildon. When a case is more complicated, and an RN is not sure whether a patient should take a certain antibiotic or contraceptive drug, he or she would be expected to refer to a nurse practitioner or doctor.
Allowing some, but not all, nurses to prescribe also makes sense from a cost perspective. It doesn’t make sense to pay for extra training of RNs if they’ll work in a setting where they won’t need to prescribe, says Agnew. “Imagine the cost of training 100,000 more prescribers, it boggles the mind,” she says.
In all three potential models, the College of Nurses of Ontario will determine what education RNs will be required to have before they are able to prescribe, and how RNs and their employers will decide when a RN has the skill and knowledge to prescribe in particular circumstances. They will also have to put in place regulations and policies to monitor the safety and appropriateness of RN prescribers – just as they currently do for NPs.
Whatever solutions are chosen, Malek is happy to see that the Ministry is asking the question about how to revamp health care roles to better meet patient needs. “It’s exciting times for health care to see interest in expanding access to patient care,” he says.
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Graduate and hire more NPs to fix the problems, nurses are burdened enough with task… dont add more !
The problem with RN Prescribing Medication, is that if you live in a big urban city there are interns or post graduates medical student residents doctors in tertiary hospitals who are under a senior medical doctor who can diagnose prescripibe medication and order tests, you do not need Nuese Practitioner or RNs prescribing they are not indispensable as a medical doctors have surplus of resident doctor physicians they are performing, they are trained to act as doctors receiving training towards there licensing and are cheaper then nurse Practitioners, nurse Practitioners are not indispensable and RNs are not indispensable to act as doctors since we have post graduate intern residency student doctors
yes,i am agree for those areas where the doctor or NPs not available because do some thing is better then nothing for life.
It’s about time! Most RN’s are more than capable of providing this and with the help of the college will not only save money but create a much needed increase of the quality of care needed. I do agree that there has to be protocols in place but it isn’t any different from what RN’s are doing currently.. just giving more room for them to save money but more importantly save a patient from waiting and enduring longer wait times for care. It’s a no brainer .. provide training and see the outcome.. that’s basically the NP’s position.. it’s all about providing the adequate training. I know as a Canadian trained RN, working currently in the USA,which I’m very proud of, has helped me save thousands of dollars taking care of my own family.. we have co pays and have to meet deductibles so I’ve been more astute in researching and using my invaluable skills as an RN to treat my own family with great success. Not every RN will want this responsibility and therefore should not be expected nor forced into doing such, but I believe that it should be made available to those that feel they could compently make that decision and move forward.
Thank you!
Cosmetic nurse injectors
Should be able to prescribe treatments and protocol to prevent complications ( anti-viral for cold
Sores ect)
Stupidest idea ever. Is this the government just wanting to provide more patient access to care at a shittier standard?
I agree. NPs were supposed to see the run of the mill patients and GPs the more complex ones. Now we are waking RNs who are not trained to do the job of an NP and an NP the job of a GP. Ridiculous
I think they should not be able to unless it is an ongoing med, because some RNs are just not smart enough or have them aquire an additional degree, I don’t trust it, I recently had a ARNP prescribe leviquin for a infection and it was a horrible exp with side effects and she knew I was on a blood thinner and did not tell me to see my PT/Inr doctor to take readings, she should have known or not been able to perscribe that. it s just wrong, it makes me want to smash her in the face the pain I went through with that med, and they never apologize and just prescribe some other dangerous med to try out, just leave it to the doctors they have training and volumes of knowledge
I do not support RN’s to prescribe independently!
There are too many risks for this independent practice for RN’s from a liability perspective and risks to the public @ large no matter how proficient and seasoned RN’s may feel they are. RN’s should be required to collaboratively consult with doctors and nurse practitioners and pharmacist’s to ensure safety for all the populations they serve. It is imperative that they have the education and training to enhance their knowledge base for appropriate assessments but collaborating with doctors and nurses & pharmacist’s ensures BEST PRACTICES for individuals and not the generalized mass populations versus the unique patient!
It is evident according to the independent investigation as per that Health Canada Reports /outcomes that populations that are the most vulnerable are being under-serviced due to lack of regulations, protocols, access to multiple health disciplines & expertise. These vulnerable populations are compromised in comparison to health care services provision in areas that have appropriate health care providers but still underutilized.
I am a nurse practitioner who has extended my education after many years of nursing to become a nurse practitioner. I believe that nurses need experience and more education to be safe at diagnosis, prescribing and make a treatment plan. I have worked with may nurse over the year who are very capable of assessing patient, but the jump to diagnosis and prescribing medication is a big one. There is not enough base education and knowledge about diagnosing disease in the nursing curriculum, for new nurse to prescribe. As a new graduate I learned on the job for many year, before I became a nurse Practitioner. A trades man would not be about to be a foreman out of trade schools so why would be trust nurse to have expert nursing skills out of school. Nurse Practitioner have fought hard for the privilege, nurse should have to prove
themselves as well, allowed the privileges granted to nurse practitioners. A high degree of education and experience is necessary to be to compliment and safe at diagnosis and prescribing.
As far as I’m concerned only doctors should be writing out prescription, for their patients.with all the breeches in the healthcare system today trust has been lost. Medications being stolen from hospitals and patients. Let doctors prescribe .
if they truly are looking to streamline care how about this to think about: send everyone to the pharmacy with a diagnosis, plan, and history and let the pharmacist prescribe…this way people can get followed up for chronic conditions without having to wait for an appointment. Similar to the supplementary prescribing model but even more streamlined. would avoid polydoctoring as well if people get them filled at the same pharmacy. would benefit from adjusting and optimizing of chronic and complex medications where they are supplied
RNs are allowed to dispense, now allowed to prescribe? It appears that the government is hoping that RNs fill the void of all of the other healthcare professions, and doesn’t value the expertise these other professions deliver. Often most RNs feel overtaxed with the amount they have on their plate, so add another thing to their list to be competent in?
The examples they use seem rather simplistic. A urinary tract infection, URTI, or topical infection can seem innocuous, but seeing as how we have multi-drug resistant bacteria arising in alarming numbers without new antibiotics, and that physicians/NPs do a poor job of judiciously prescribing antibiotics (save those in infectious disease specialties), I can see increased rates of drug-resistant infections rising in nursing homes and in the community if more people are given the authority to prescribe.
The evidence as stated in the article above, appears to be of poor quality and has bias as to the effectiveness of RN prescribing. There is no net positive or negative benefit, so what is the motivation behind legislating RN prescribing. It also dilutes the differentiation of NPs from RNs, which would decrease the amount of RNs wishing to become NPs.
I can only conclude that the motivation is political as the number of nurses exceeds that of physicians and NPs.
Let’s focus on what each professional does best. Physicians and NPs diagnose and prescribe, pharmacists dispense, modify and monitor pharmaceutical therapy and Nurses are experts in administration and delivering care to their patients.
In the end, this may seem like a positive to RNs, but it opens the profession up to make more errors and opens the door to being less qualified in other areas. Ever here of the expression – Jane/Jack of all trades, Master of None.
This will only increase the overprescribing of antibiotics leading to more antibiotic resistant organisms. I also agree that RN’s may be lacking assessment skills to determine cause of illness. Mired should not be prescribing and diagnosing
If Rn’s are allowed to prescribe medication and diagnosis, will they still be required to change diapers, wash patients and feed patients. it seems like a big responsibility to prescribe if they still have to do these basic tasks?
Considering I have been wrongly diagnosed by a doctor who has years of medical expirence and schooling behind them, I am very uncomfortable with this.
I would support ‘protocol-based RN prescribing’ because it brings the knowledge of medical professionals and registered nurses together in ensuring better outcomes for patients.
No as this compromises patients care. It’s a very dangerous move by the Ministry. Subsidized nurses education instead to be NPs to resolve the shortage of healthcare providers.
If RN’s want to prescribe medications they should become NP’s, doctors or physician assistances. There are currently unemployed NP’s in Ontario who have the education knowledge, skill and training to prescribe- they should be utilized. I strongly disagree with RN prescribing. You don’t know what you don’t know! DM Martin MN-NP
I couldn’t agree more with you!!
Pharmacodynamics, pharmacokinetics, have RN been taught that and been examined to be deemed competent?
If not, then prescribing is not for them. Clinical judgement alone is not sufficient to ensure safe prescribing.
Yes rns Learn all of this is the BScn degree currently.
but not at the level of NP/GP. And prescribing is just about pharm, its about knowing the disease process, the evidence, and differentials to consider
the basic educatinal qualification for enterence for medical graduate course & nursing is equal( 12 th std or puc in science subjects) the training period for nurse 3& 1/2 for mbbs 4&1/2 yrs the syllabus is almost same . then why the nurses are not allowed to treat minor ailments, communicble deseases, minor processors, deliveries without surgeory,etc&many more activities. in rural&remote areas where the nurse vaccinate achild incase any reaction by any vaccine occurs the shoud not wait for physician she shoud start immediate preventive act to save life of the suffrer. so it is neccesity for human wellbeing to authorise & protect nurses against legal action .thanks.
giving registered nurses prescribing authority isn’t really helping expand access to medical care. i have lived in a rural area all my life and have seen family physician and nurse practitioner. i only saw a nurse pracitioner when my family physician wasn’t available and i could definitely tell that family physicians were more knowledgeable. it’s true that the nurse practitioner spent more time with me, but that’s because she was very unsure of herself and how to manage my condition. i was sort of happy to be able to see a nurse practitioner, but then i had to run all of my problems by my family doctor again. i feel it was second class care. now registered nurses want the authority to prescribe. i’m not sure what class of care this will be, but it’s not fare to people in underservied areas to get care by less knowledgeable and experienced providers.
the nurse was unsure because she have noright to prescribe & manage your illness so she was afraid of any type of legal action which would be taken against her in the adverse situation but the physician is covered legislatively
They are extremely knowledgable! Maybe this np was brand new and just graduated. New mds are just as unsure.
Its’s not a good idea to base opinions on an isolated incident. RN’s and even more so NP’s are highly educated. Any novice professional can be unsure this does not represent the entire profession.
in addition to the numerous valid concerns about nurse prescribing mentioned above, it should also be mentioned that RNs are nearly never the most responsible health professional. having nurses prescribe medications would only make it more difficult and confusing for physicians to manage patients.
Evidence shows that RNs that received the right training can prescribe and be as safe as others who have the authority to prescribe, see the track record in Ireland.
This is Canada, not Ireland.
Stop RN Replacement. Start Independent RN Prescribing.
Maybe if RNs salaries weren’t so high, we wouldn’t have to replace them
RNs in their area of expertise are poised to prescribe and thereby increase access to timely healthcare.
RNs do not have a specific area of expertise and are not experts. They simply work in a particular area in a hospital or clinic. They never received in-depth training in general or specialty practice. And it is my thought that most RNs realize this. It is a distinct minority that believe otherwise.
Indeed.
Rns receive a 4 year university degree. This allows them to work in a general medicine floor. To work in emerge/ icu, dialysis etc etc they must do extra school which can be 2 years in length. So yes they do have expertise in a speciality.
RN’s do specialize, and there are many area’s of specialty accompanied with further education and training. There are general practise and specialized nurses. Please do not spread false information about the profession.
move forward now. The efficiencies will be gained with the right team. Expanding access to care support full scope of practice.
pharmacology is a speciality. do any one of us truly know enough about it to safely prescribe meds? did your bscn or diploma teach you all the details of pharmacology and drug classifications? besides, aren’t we busy enough?!?! a stupid and unsafe idea frankly.
Yes thank you Susan, 100% agree! Read my statements above. :)
I support Registered Nurses prescribing medications in their area of expertise.
…so you don’t support RNs prescribing?
let’s say your area of ‘expertise’ is renal. so you think you can only Rx ‘renal meds?’ chances are, patients come in on cardio meds, renal meds, arthritis meds, diabetic meds, prostate meds—–all at the same time. so pray, tell me, what are speciality meds and how do you know the reactions to all the other meds patients are on?
i have been an RN for twenty five years and am strongly against this proposition. there is risk involved in prescribing and i am concerned about the prospect of being sued.
I am so thankful that some people see the dangers in this. It is not safe and I feel so bad for the patients and families of those who the mistakes will be made on. None of us are perfect and we all make mistakes however, allowing options such as RN prescribing will open things up for more mistakes is not the appropriate way to go.
at the rate kathleen wynne is replacing RNs with RPNs, there will be no RNs employed to prescribe. out of curiousity, why not allow RPNs with experience in a certain area to prescribe?
as an RPN, i feel comfortable being able to prescribe if i have enough experience in a particular area.
Never, what an insult!
This is crazy!
So now it was from MD to NP to RN to RPN? Really? Don’t get your hopes up Jose, you have no idea how advance pathophysiology, advanced pharmacology and chemistry etc has to be understood in order to actually know what you are doing. There is a reason why those who enter RPN school only have a 2 year program just out of high school. There is much more to this then just prescribing a med. These are peoples lives and it would be 100% unsafe for an RPN to even consider such a thing! NPs have a minimum of 6 to 7 years of school to do what they do, there is no way that it is safe for someone to go to school for 2 years and do the same thing! If you really want to expand your scope, then go back to school and do it right instead of taking the easy way out!
RN prescribing will save the health care system money. We will no longer have to hire NPs.
Not true…there is a difference between independent practice and independent prescribing.
NPs will still remain highly effective for our patients and health care systems.
What about PA’s?
What about them? They are unregulated.
So are paramedics. Why don’t we just get rid of them too?
PAs are unregulated because HPRAC concluded that the current model of delegation and small number of practicing PAs meant that they could not meet the requirement of demonstrating harm if
NOT regulated. Also, I’m sure there were other political and bureaucratic reasons for the snub…
This poll is quite concerning. Most of the people voting are no doubt nurses, given that this debate has been published almost exclusively on nursing sites. The fact that only 57% of voters, most of whom are probably RNs, seem to agree that RNs should be able to prescribe medications, tells me that people are not for RN prescribing. To be able to prescribe, it is first necessary to diagnose, and given the amount of training RNs receive, they simply do not have the skills to do this.
I agree with you here Jamie. Most are probably RN’s voting. I think there are a small part of RNs that like the “power” and “status” it may bring them… an easy way for them to advance in their career without taking the appropriate schooling needed to actually become an NP. I worked very hard to be an NP and although I feel it would be helpful in sexual health clinics and for vaccinations and possibly long term care, I do no feel it is necessary anywhere else! It is actually quite insulting to us NPs who have paid the money, the sweat, the tears and the years of becoming an NP for.
It angers me that this is even being considered! There are so many potentially dangerous outcomes like allergies, resistances and serious illnesses that could put a patient at significant risk and I do not believe that a measly 300 or 400 hours could ever satisfy threat.
Hi Donna,
Thank you for becoming a NP. It is much needed in our country right now.
However as a NP, I thought you would be open minded to the idea of expanding the scope of the RN to meet the populations needs.
It wasn’t very long ago, that NPs were granted prescribing priviledges…and surprise, they also needed education surrounding prescribing to ensure safe and effective outcomes for their patients. Physician’s were highly against NPs even taking some of ‘their’ role away. Or just looking at the evolution of the RN profession alone, you are aware of the fights we have had to undergo to prove our “worth and knowledge”, so to say that RNs don;t have the training to take this task on is just ridiculous. In order to become prescribers, they will have to work in their care areas for over 3 years, the employer will need to recommend them for the training, and then they will undergo the training which also includes clinical placements. Since Canada is also promoting the idea of RN prescribing with the use of clinical decision making tools for the RNs, they are highly supported in their clinical areas for success.
Much of the data also supports the idea that there has been no difference in the appropriateness, safety or prescription choices made by RNs versus physicians and NPs worldwide. One study even reported an increase in physician support for RN prescribing, after they were involved in independent auditing of RN prescribers, and realised that the RNs were making the same prescription decisions they would make in accordance to their MD training.
Canada is only looking into implementing RN prescribing into primary health care, long term care and community settings at this time, not hospital or other acute settings, in order to improve access to care (specifically in rural and remote areas where physician and NP access is limited), enabling NP and physicians to focus on pts with more complex issues, and “unlocking the system” (decreasing wait times, decreasing unnecessary appts, decrease risk of hospitalizations and faster recovery from illness/injury/surgery).
It has also been reported that the majority of prescriptions for RNs have been for contraception, dressing materials and incontinent products/care.
RNs are also a profession that is highly recognized for our ability to be honest, transparent and critical thinkers THEREFORE if one suspected a patient needed more care then their scope could provide, they would refer a physician or NP, WHICH is what they already do in primary health care, long term care and community settings.
RNs would also become aware of allergies, resistances and serious illness that could effect the patients just as you have done in your education, prior to practicing prescribing.
We must remember that no one was born a professional, and with additional training and preparations, we should embrace the evolution of the RN.
Who knows, this may allow you to enhance your practice in the future, which I am sure you would embrace and hope to be supported by your fellow medical community members. Afterall, I think we are all on the same page that we want what is best for our patients, and again research from around the world, as proved that RN prescribing as only positive effects for our patients and health care systems.
Perfectly said!
That’s not fair. As RN’s we are equally aware of allergies and interactions.
We need to support a voluntary, independent RN model of prescribing including the ability for RNs to order diagnostic testing and communicate a diagnosis to provide care. There are 96,000 RNs working across Ontario – This is the bold direction our health system needs.
When an RN feels confident and has worked in a specialty area for many years, allowing the RN autonomy to practice at a more efficient and higher scope of practice makes sense. After working many years in a sexual health clinic, I felt very comfortable and could see myself prescribing medications for sexually transmitted infections (I did it everyday, but, had to have the Physician sign for the meds I dispensed daily under his authority/order) I used my knowledge to recommend the mediactions, and the physician I worked with supported my judgement (for ordering lab tests too)
By increasing the capacity of the RN (with an additional 300-hour course as recommended by RNAO) It will assist with:
• Timely access to quality patient care
• health system effectiveness
• Vulnerable populations will be able to gain access to primary care.
• Residents in long-term care will still experience unnecessary transfers to the emergency departments
It just makes sense.
~Dana Boyd RN MN, Public Health Nurse, Windsor, Ontario, Canada
by this logic, if you’ve followed a cardiologist around long enough, there is no need for the cardiologist. RNs can just do the job of the cardiologist. i mean they’ll have their 300 hour course, so that’s equivalent to the 4 years of medical school and 6 years of residency of the cardiologist.
I’ve watched Sidney Crosby for years. I bet I’m ready for the NHL now.
Prescribing wouldn’t be a role added to nurses in settings where there are already prescribing HCP practising. So this isn’t a worry for the bedside nurse, it concerns community nurses and those in rural areas where accessibility is limited. This would definitely improve health outcomes in those circumstances. We shouldn’t think of this in terms of increasing the role, “privilege”, or even workload of the RN but, in terms of patient outcome. Let’s take ego-self out of this very important issue. And it’s been made very clear that this is only for simple issues/basic medications.
I feel that if it’s come to the point where we are discussing giving RNs the privilege of prescription, then I feel it is also important to discuss giving OTs/PTs, pharmacists, acupuncturists, and heck, even naturopaths prescribing rights (I think I read something about them wanting to prescribe too). All in the interest of expanding roles that need not be expanded in the first place. There is such a thing as enhancing one’s skills, but there is also such a thing as respecting boundaries of practice. Why continue to blur the lines? Why make things more confusing for patients? Why should patients be the ones to pay for these mistakes?
I agree with you. As an NP, I know that RNs are not trained to prescribe. I worked as an RN for 7 years before becoming an NP, the knowledge Gap is just too much.
absolutely not. as it stands, it takes nurse practitioners 1 hour to see a patient a GP would normally see in a quarter of that time, and even then, their diagnoses are likely less accurate, regardless of what various articles, most published in nursing journals (?conflict of interest), will say. how could a registered nurse possibly be able to do the job an NP is already not trained to do?
Using different models of practice require different time frames and more patients in less time does not mean betree care. Again respectfully roles are different and bring much to the patient experience, we can all be part of this change and responsibly and respectfully discuss how to include RN prescribing.
Know your limits.
Prescribing is not easy. It is a decision made after careful consideration of all facts and possibilities. It is the end-result of a consultation by a highly educated and responsible professional.
RNs do not have the necessary training, or dare I say academic fortitude, to be given the privilege of prescription.
agreed, Han
This is a purely uninformed and dare I say, misogynistic, response.
haha, my misplaced commas don’t help my argument here!
I support Registered Nurses prescribing drugs.
I would support the position of Barb Mildon – yes, but circumscribed (in a limited range of settings). I do not see that option here in the vote. I also would say that this has implications for nursing education. Let’s proceed cautiously.
Absolutely not! We’re asking them to full fill a role that they want but lack the education, skills and experience to carry out.
They will be taking a 300 hour course. The education will be upped from a 4 year degree to 6 or 7. Do some research Margret.
so why not just go get you NP training?
I think RNAO and ONA have more important things to champion. St Jose’s in Hamilton just layed off 84 Reg N’s in favour of RPN. The last time Cambridge Hospital layed off RN’s and replaced with PSW’s the paper read’ “Better Care.” Our Hospital Grand River, is replacing some RN lines for RPN’s.
Dialysis has RPN’s working, but it is not very effective, for patient care.
Who is the watchdog to ensure that Patients are receiving safe, efficient and ethical care.??
The CNO has criteria to determine the right nurse for the right job.. So why are the policy makers allowing the shift in Registered Nurses.??
I am sooo glad I am at this end of my career. I wonder what Nursing will look like in the very near future, and the impact it will have on our precious patients.
The International Council of Nurses (ICN) congratulates Ontario for moving forward with authorizing registered nurses (RNs) to prescribe medications. We are pleased to provide you with feedback to support this initiative, given our international experience.
Globally, health systems are in a state of change. Jurisdictions, which historically had a down-stream and illness focus, are shifting towards more upstream and wellness-based cultures of health promotion. We are aware that Ontario is in the midst of striking improvements to make your health system more person-centred. RNs have an opportunity to play an immensely important role as catalysts for positive change.
ICN knows that healthy public policy embraces teams, autonomy and draws upon the diverse strengths of all groups within a community. Interprofessional health service delivery, through the full utilization of all health professionals, translates into healthy public policy. Independent RN prescribing advances global health equity as it greatly improves access to health services, especially for those who face some of the greatest challenges accessing service.
Moreover, independent RN prescribing enhances patient safety through clear accountability and will stimulate the development of a global nursing knowledgebase, including clinical practice resources to continually enhance RNs’ competency, knowledge and skill.
Independent RN prescribing is evidence-based and critical to enhancing the resiliency and capacity of health systems to respond to emerging threats, including infectious disease. Research shows that RN prescribing has a significant impact on the health of the public. For example, it is advancing the management of HIV in Africa (see Monyatsi et al 2012; Barton et al 2013). The United Kingdom has 17+ years of experience with independent RN prescribing
and demonstrates strong outcomes for the public.
ICN advises in the strongest possible terms that Ontario adopts an independent model of RN prescribing through an enabling legislative and regulatory framework. Doing so will contribute to a global movement that maximizes the role of the RN to improve health outcomes for all.
Thankyou Judith for your thoughtful professional respectful response.
Thank you for your strong evidence-based response to RN Independent Prescribing. In support of health outcomes for all, Stop RN replacement, Start RN Independent Prescribing.
Thank you Judith, for your insightful comments. RN Independent Prescribing within our area of expertise after successfully passing an approved course will safely enrich and enhance our patients’ health outcomes.
Yes, thank you for this evidence that RNs are capable and responsible clinicians who are well positioned to deliver safe and effective healthcare.
Health care is changing our roles are changing RN’s are more prepared than ever to practice at full scope. We need to be inclusive nurturing collaborative and work as a health team respecting our roles and the capabilities we bring to the system for the patient.
We will all be paitents and want an efficient affordable system.
As a nurse practitioner, this is what I thought I had signed up for but now they are proposing that RNs do our job and that NPs do the same jobs as the doctors, see medically complex, less run-of-mill patients. Because this is currently what I have been doing and the government seems to have finally realized it, I hope our salaries are going to reflect that we see medically-complex, less run-of-mill patients with the roll out of the 85 million. I’m tired of practicing like a doctor yet receiving the pay of a nurse!
I think RNs in public health should be able to prescribe medications pertinent to their practice such as in travel immunization and sexual health clinics. I think RNs should be able to extend prescriptions for long-term medications. I am less in agreement with acute, episodic because what is booked by reception as an acute, episodic illness often turns out to be more complicated, for example, the patient has recurrent UTIs, poor renal function and allergies to three commonly used antibiotics or the person with the supposed cold is an elderly person in heart failure. Receptionists don’t have time to ask patients a lot of questions to triage the patient well. What you are basically asking is for the receptionist to make the diagnosis of acute, uncomplicated UTI over the phone in less than 30 seconds and the diagnosis usually comes from the patient saying, “I have a bladder infection”. The patient arrives and the problems is more complicated and the doctor and nurse practitioners are already booked with people who probably could have waited until the next day to be seen but now they will be double booked having to deal with their own scheduled patient and now a complicated UTI.
If you wanted to practise and be paid like an MD, why didn’t you go to medical school?
Mike,
The medical model and nursing model are different. One is not better or worse than the other, just different. I prefer the nursing model of care over the medical model.
What she is referring to is that hospitals are using NP’s as physicians because NP’s are paid less. It’s ironic that medical associations like to tout NP incompetence (without evidence to support the argument) and yet in practice, use NP’s to the full extent of their education – at a bargain. In the acute care setting, NP’s are cheap labour. The only way to avoid that difference is to work only in private practice – but even there, the reimbursement rates are lower for NP’s for the same diagnosis.
The issue largely surrounds the perception that Nurses are just a bunch of pretty girls. RN education is intense with a failure rate that approaches 50%. A further 50% of new RN’s quit the profession within the first year and never return due to physician and patient abuse. NP and MD education are both graduate level studies. They are difference because one is the nursing model of care and the other is the medical model. To argue that an NP should be an MD for equal pay makes little sense. Physician Assistants are paid more than NP’s and have less education and experience at the onset of their careers. PA’s also do not practice under their own license. They must have physician oversight. This is about control, not patient safety or practice competence.
NP’s choose their profession because that is their chosen career, and not because they could not get into medical school. If NP’s are being used to the full extent of their license and education, then they should be reimbursed at the same rate as MD’s for the same diagnosis.
EB
Had a different experience working in cardiac surgery. The surgeons love having NPs vs hospitalist follow pts post op because 1. NP’s had years of cardiac experience as RNs and implemented musing philosophy in delivery of pt care as NP’s 2. NP’s help to elevate to skills of RNs in same area which benefits patients 3. Hospitalists function from the medical model whereas nurses engage in client centered care 4. NPs stay on the unit whereas hospitalist generally round and leave. 5. Cardiac surgeons in this area were pooling monies out of pocket to increase NP wages!
Physician Assistant here. Just want to chime in that we do not make more money than NPs – our salaries are capped much lower in fact. Family health teams are given more funding for NPs than PAs, and in hospital, because we have not been around as long as NPs, HR has set the range to be lower than NPs. Where I’m working, the difference is about $35,000, although we have NPs and PAs on the same team, essentially doing the same job.
While PAs aren’t independent, that doesn’t mean that we are lesser or not as educated as NPs – we are trained in the medical model of care and our clinical placements are 1800 hours vs the 800 hours required in NP education.
The way that I see it, PAs are trained as generalists, and as a result, must have oversight, whereas NPs must identify an area of practice (primary care, adult, etc) which they learn in depth, and thus are able to practice independently. Of course, I know many primary NPs now working in medicine, but again, we underestimate the role of on the job training and ongoing clinical experience. We can all learn if given the opportunity.
One issue is that while NPs may admit/discharge to hospital, they are not being utilized as the most responsible health care provider in this setting. As a result, many NPs are still working for doctors as opposed to being most responsible for the care of a patient – in essence, they are being treated like PAs (minus all of the medical directives and cosigning), performing care under a MRP . Until we started to recognize the NP scope to its fullest potential, this will continue to be a sore spot.
Everyone likes to make this out to be a turf war, when in reality, there is more than enough work for all of us to do, and we could accomplish so much more if we worked better together!
Well…I did apply to med school was a bit of a crap shoot with 7,000 applicants for 126 spots. Had a competitive application. So NP was second choice for me. Love the work, docs are awesome politics are tricky, and pay is a bit low but that’s changing. I don’t think we should be paid as much as doctors. Doctors have more training and education, period! But looking forward to a fair wage compensation for work performed.
Good point. See post below
Absolutely!
See comment 2 posts down
Writing a prescription isn’t scalable. Every patient is unique. The prescription is a recommendation by a physician that, after a careful consultation, the patient requires x drug.
It is not so simple as “the diagnosis usually comes from the patient”, otherwise our brilliant forefathers would have given RNs the privilege to prescribe long ago.
Your comment is a classic case of “a little knowledge is a dangerous thing”.
Absolutely!
And this post brings to light that physicians are and were historically, the supporters, teachers and mentors who have assisted NPs in this age of healthcare, to practise independently within our scope, AFTER completing rigorous graduate level training and residency training. RN’s simply do not receive the advanced level education training.
Thanks to all the doctors out there who understand, embrace, support and work collaboratively with the NP’s!
As an no I can tell you that no one is proposing we see medically complex patients. If you have been doing this in the past, it opens you up to litigation.
No. It would set a dangerous precedent. Nurses have not gained the privilege to prescribe. To legislate such a change would be failing patients.
RNs are held to professional standards, and they should be here, too. I think there are very appropriate rationales for extending nursing practice into the realm of limited prescribing privileges and our practice standards would keep patients safe as they do now.
The difficulty with RN’s prescribing is the same with MD and NP that most do not prescribe appropriately. There is plenty of evidence that indicates the over use and inappropriate us of prescription drugs is happening and adding another prescriber to the mix is the wrong solution for the problem that is identified. The misuse of anti-infective drugs is common and unless there is an effective way to get all prescribers to follow protocol we will see this problem continue. There need to be a rethink of the whole area of diagnosing and prescribing long before we just extend a professional privilege to another profession.
Ms. Lindberg, I think you are spot on. I think we should treat antibiotics the same as we treat opiates. (almost the same)
It occurs to me, on reading your comment, that the opportunity to inject the up-to-date education into the system (of which nurses make up the majority) could make a huge impact on this very issue. Empowering nurses to prescribe opens wider the dialogue around use of medications as nurses categorically emphasize non-pharmacological intervention in nursing practice. We promote healthy lifestyle, prevention at all levels, community health, chronic illness management, symptom management – we focus on the non-pharmacological. It stands to reason that RNs could really shift the system away from over-use.
This article ignores an important issue. There are many RN’s that are directly/indirectly employed by pharmacies and pharmaceutical companies to support patient care (examples include Pulm HTN, HCV, Biologics). Pharmacies and Industry would LOVE RN’s to prescribe and cut out the pesky MD. I wonder how the regulatory framework will evolve to address this issue if RN’s can prescribe given the obvious bias and possibility that treatment is prescribed for financial benefit. Is there an appetite amongst nursing regulatory bodies to address bias, maintenance of competence, and prevent RN’s being paid for by treatment monies from prescribing, While MD bias certainly can exist, at least they generally cannot be employed for patient care by those who stand to benefit most by the prescribing of medications while RN’s do right now.
Reality check! Take a look at the “new age” 21st century registered nurses. For years registered nurses traditionally worked only in hospitals, health care institutions, public health settings, research, and government services, where they had significant contact and professional interactions primarily with other health care professionals.
Today’s decision makers need to recognize “new age” registered nurses. Statistically 40% registered nurses work in independent practice delivering a huge diversity of nursing health care services. These independent practice nurses connect people to health care system by navigating them to correct resource, by education or work as clinicians providing required health care. These “new age” nurses in independent practice are a significant change from the traditional hospital registered nurse. Public education booklet http://www.ipnig.ca/cottagecountry-2015/Nurses-OnlineMagazine-JUN2015.pdf
Today’s society is shifting towards a new trend to meet health care needs. There is a growing demand for comprehensive community, family and individual Primary Health Care PHC model of health care delivery. Important to note that PHC model of health care delivery is distinctly different then primary care that is a person first entrance to medical care system at their doctor or hospital.
Public demand is increasing daily for an even greater diversity of available health care services and available skilled health care providers to meet the needs of a “new health conscious society”. Many independent practice registered nurses have stepped up to meet this need delivering professional specialized nursing health care in the community where people ” live, work and play.”
The “new age” nursing services focus on enhanced health, prevention, education, protection, health maintenance and chronic care. Experienced skilled registered nurses, utilizing new and innovative health care technology provide evidenced based nursing skills to meet the health care needs of all people.
It is time for independent practice registered nurses to enhance their full nursing capabilities in their specialized nursing scope of practice with the addition of independent registered nurse prescription. The public are ensured all registered nurses often with nursing certification accreditaion are bound by regulatory legal nursing scope of practice soon to include independent RN prescription
fantastic message. Send out far and wide. You are a great advocate for quality care and the direction of nursing. Stop RN replacements now. Make a capital investment today.
If RN’s want to prescribe medications they should become NP’s, doctors or physician assistances. There are currently unemployed NP’s in Ontario who have the education knowledge, skill and training to prescribe- they should be utilized. I strongly disagree with RN prescribing. You don’t know what you don’t know! DM Martin MN-NP
Many MD’s are supported by big Pharma dinners lunches research don’t single out RN’s the money is benefited by all parties with a smile. That is not the issue being discussed though.