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Approved by the College of Registered Psychiatric Nurses of Alberta (CRPNA) Provincial Council March 2022.
Permission to reproduce this document is granted. Please recognize CRPNA.
College of Registered Psychiatric Nurses of Alberta (CRPNA)
Suite 201, 9711 – 45 Avenue
Edmonton, AB. T6E 5V8
Phone: (780) 434-7666 Toll Free 1 (877) 234-7666
Fax: (780) 436-4165
Email: [email protected]
Website: www.crpna.ab.ca
College of Registered Psychiatric Nurses of Alberta (CRPNA) would like to acknowledge and thank the College and Association of Registered Nurses of Alberta (CARNA) for their support and allowing the use of their publications to develop very similar work on all documents created by CRPNA for RPN Restricted Activities Standards. All CARNA documents related to RN Restricted Activities Standards will be acknowledged and referred as valuable resources in CRPNA’s documents.
The Registered Psychiatric Nurse Profession Regulation (RPN Regulation) authorizes the restricted activities regulated members may provide and the categories of regulated members that are authorized to perform them. However, the authorization of a restricted activity in the regulation does not mean that a regulated member can perform any identified restricted activity in any situation, in any practice area. The College of Registered Psychiatric Nurses of Alberta (CRPNA) is required to create standards of practice articulating the minimum requirements of regulated members performing restricted activities.
The Health Professions Act (HPA) introduced the concept of restricted activities, as those high-risk activities performed as part of providing a health service that requires specific competencies to be carried out safely by authorized persons. The HPA provides authority to the regulatory college to make a regulation that authorizes those restricted activities in Schedule 7.1 that its REGULATED MEMBERS may perform and any conditions or supervisory requirements.
PURPOSE
All RPNs are responsible and accountable for their practice. All RPNs are responsible and accountable for adhering to the Health Professions Act (HPA), the RPN regulation, Standards of Psychiatric Nursing Practice, Standard of Practice Maintaining Professional Boundaries and Preventing Sexual Abuse, and Standards for Registered Psychiatric Nurses prescribing schedule 1 drugs and ordering diagnostic tests. This document builds on those documents to further articulate and define the scope of psychiatric nursing practice for the public, regulated members, and other stakeholders.
This document identifies standards and expectations for performing restricted activities by regulated members. Restricted activities are only one component of client care and do not encompass the whole of psychiatric nursing practice. The performance of a restricted activity in the provision of client care must be performed with:
- A comprehensive client assessment (physical and mental)
- Critical thinking and clinical judgement, CRITICAL INQUIRY
- Treatment Planning
- Problem solving
- Decision making
- Monitoring client responses
- Evaluation
These standards provide further clarification and direction on the provision of a restricted activity within the context of psychiatric nursing practice. These standards identify the expectations for regulated members who perform restricted activities. All RPNs must practice within the limits of their own competence and perform restricted activities that are appropriate to their area of practice. This document supports and builds on other CRPNA documents that articulate and further describe the scope of psychiatric nursing practice for the public, regulated members, and other stakeholders. All documents can be found on the CRPNA website at www.crpna.ab.ca.
Authorized Activities
15(1) A regulated member registered on any category of the regulated members register may, within the practice of registered psychiatric nursing and in accordance with the standards of practice, perform the following restricted activities:
(a) cut a body tissue to administer anything by an invasive procedure on body tissue or to perform surgical or other invasive procedures on body tissue below the dermis or the mucous membrane.
(b) insert or remove instruments, devices, fingers, or hands
(i) beyond the cartilaginous portion of the ear canal;
(ii) beyond the point in the nasal passages where they normally narrow;
(iii) beyond the pharynx;
(iv) beyond the opening of the urethra;
(v) beyond the opening of the labia majora;
(vi) beyond the anal verge;
(vii) into an artificial opening in the body;
(c) insert liquid into the ear canal under pressure;
(d) dispense, compound, provide for selling or sell a Schedule 1 drug or Schedule 2 drug within the meaning of the Pharmaceutical Profession Act;
(e) administer a vaccine to those age 5 years or older;
(f) administer parenteral nutrition;
(g) administer blood or blood products;
(h) administer diagnostic imaging contrast agents;
(i) administer anaesthetic gases, including nitrous oxide for the purposes of sedation;
(j) administer radiopharmaceuticals, radiolabelled substances, radioactive gases or radio aerosols;
(j.1) to order or apply non -ionizing radiation in ultrasound imaging other than the application of ultrasound to a fetus.
(k) perform a psychosocial intervention with an expectation of treating a substantial disorder of
thought, mood, perception, orientation, or memory that grossly impairs.
(i) judgment,
(ii) behaviour,
(iii) capacity to recognize reality, or
(iv) ability to meet the ordinary demands of life.
(2) Despite subsection (1)(d), a regulated member registered on any category of the regulated members register who is performing the restricted activity described in that subsection shall not distribute, trade, or barter for money or valuable consideration, or keep for sale or offer for sale a Schedule 1 drug or a Schedule 2 drug but may distribute or give away a Schedule 1 drug or a Schedule 2 drug without expectation or hope of compensation or reward.
(2.1) A regulated member registered on the registered psychiatric nurse register may, within the practice of registered psychiatric nursing and in accordance with the standards of practice, perform the restricted activity of ordering any form of ionizing radiation in medical radiography
(3) A regulated member with advanced training approved by the Council may perform the restricted activity of administering a vaccine to persons less than 5 years of age.
(4) A regulated member may perform the restricted activity of reducing a dislocation of a joint with the consent of and under the supervision of a regulated member of another college if the Council of that college, by regulation, authorizes a regulated member under Schedule 25 to the Act to perform that restricted activity under the supervision of its regulated members.
15.1 Restricted Activity requiring prior authorization.
A regulated member on the registered psychiatric nurse register who meets the requirements approved by the Council and who has been authorized to do so by the Registrar or the Registration Committee may, within the practice of registered psychiatric nursing and in accordance with the standards of practice and the scope of the authorization given by the Registrar or the Registration Committee, perform the restricted activity of prescribing a Schedule 1 drug.
Restriction
16 Despite sections 15 and 15.1, regulated members must restrict themselves in performing restricted activities to those activities that they are competent to perform and to those that are appropriate to the member’s area of practice and the procedure being performed in accordance with the standards of practice governing the performance of restricted activities.
The regulated member is responsible and accountable for the restricted activities they perform within their psychiatric nursing practice.
The following criteria illustrates how the standard must be met, and all criteria must be met in order to achieve the standard. The criteria are not written in any order of importance.
CRITERIA
Every Regulated Member in the Performance of a Restricted Activity
1.1 is accountable for their practice including the safe, competent, and ethical performance of restricted activities:
1.2 only performs restricted activities they are authorized and competent to perform, appropriate to their clinical practice area, and the procedure being performed
1.3 complies with organization policy and only performs a restricted activity that is appropriate to the clinical practice area; and
1.4 only supervises the performance of restricted activities that they themselves are authorized to perform without being required to be supervised themselves.
The registered psychiatric nurse
1.5 who is authorized to prescribe Schedule 1 drugs within the meaning of section 31 (1)(b) or (c) of the Pharmacy and Drug Act and to order diagnostic tests in a specific clinical practice area, must practice in accordance with the standards and criteria outlined in the Registered Psychiatric Nurse Prescribing Schedule 1 Drugs and Ordering Diagnostic Tests Standard (2021)
1.6 must use the appropriate clinical support tool in their specific clinical practice area to order medical radiography and must:
1.6.1 use the guidance and advice provided by CRPNA to determine the knowledge and skill required to perform the ordering of medical radiography safely and competently,
1.6.2 successfully complete any additional education required by their employer in that specific clinical practice area,
1.6.3 know the evidence-based rationale to order the medical radiography as outlined in the clinical support tool,
1.6.4 notify a client of any necessary immediate or follow-up care,
1.6.5 document all interactions with a client, including all interactions, therapies, procedures performed on/with the client including any failed attempts to notify a client about any necessary immediate or follow-up care,
1.6.6 use critical judgment to decide if the order for medical radiography outlined in the clinical support tool is appropriate for the client in the specific situation, identify and explain any risks or complications to the client that are associated with medical radiography procedure and
1.6.7 Use the processes outlined in the clinical support tool and organization policies for:
1.6.7.1 collaboration with a health-care professional, who provides health services and is authorized by a regulation under HPA or by another enactment, to order and interpret medical radiography to
a. review results of the medical radiography and consultation report in a timely manner,
b. discuss disclosure of the results of the medical radiography to the client, and
c. discuss any necessary follow-up care,
1.6.7.2 receiving results of the medical radiography and responding to critical results reported by an imaging facility, and
1.6.7.3 identifying the appropriate health-care professionals that results are directed to; and
1.7 must not order any form of
1.7.1 ionizing radiation in nuclear medicine, radiation therapy, and
1.7.2 non-ionizing radiation in lithotripsy or magnetic resonance imaging.
The Registered Psychiatric Nurse applies, integrates, and remains current in evidence-based knowledge relevant to professional practice.
The following criteria illustrates how the standard must be met, and all criteria must be met in order to achieve the standard. The criteria are not written in any order of importance.
CRITERIA
The Registered Psychiatric Nurse
2.1 applies theory/evidence-based knowledge, skill, and critical judgement to assess, plan, implement, monitor the client’s response, and evaluate the restricted activity.
2.2 applies critical thinking and clinical reasoning and critical inquiry when engaging in a restricted activity to determine if the restricted activity is warranted by considering the known risks and benefits to the client, the predictability of the outcomes and any other factors that might impact client outcomes.
2.3 acknowledges limitations in knowledge, judgement and/or skills and seeks out appropriate educational resources if needed to perform a restricted activity.
2.4 acts and provides care if any intended and unintended outcomes arise: and
2.5 maintains competence necessary to perform restricted activities relevant to their practice.
Accountability: the obligation to answer for the professional, ethical, and legal responsibilities of one’s activities and duties (Ellis & Hartley, 2009).
Client: in this document, client refers to the individual, groups, and communities, who are the recipient(s) of psychiatric nursing services.
Clinical Support Tool: an evidence-informed tool developed by the interdisciplinary team and used by the practice setting to guide decisions related to prescribing Schedule 1 drugs and ordering of diagnostic tests. The clinical support tool may be in the form of a protocol, algorithm, or clinical practice guideline.
Competence: the knowledge, skills, judgements, attitudes, and values required for successful functioning as a Registered Psychiatric Nurse.
Critical Inquiry: is the process of gathering and evaluating information, ideas, and assumptions from multiple perspectives to produce well-reasoned analysis and understanding, and leading to new ideas, applications, and questions.
Evidence-Informed: practices use the best available research and practice knowledge to guide program design and implementation. This informed practice allows for innovation while incorporating the lessons learned from the existing research literature.
Health Service: a service provided to people to protect, promote, or maintain their health, to prevent illness, diagnose, treat, rehabilitate, or to take care of the health needs of the ill, disabled, injured, or dying (HPA 2000).
Predictability: degree to which outcomes can “reasonably be expected to follow an anticipated path with respect to timing and nature” (College of Nurses of Ontario, 2009).
Restricted Activity: the restricted activities identified in Schedule 7.1 of the Government Organization Act provide a legal framework for authorization by a regulatory college of those restricted activities their regulated members can perform.
Standard: an authoritative statement that describes the required behavior of every nurse and is used to evaluate individual performance (CNA 2010)
Brunt, B. A. (2005). Critical thinking in nursing: An integral review. The Journal of Continuing Education in Nursing. 36(2), 60-67.
Canadian Health Services Research Foundation. (2005). How CHSRF defines evidence. Links, 8(3), 7.
Canadian Nurses Association. (2010). Canadian nurse practitioner core competency framework. Retrieved from http://cnaaiic.ca/~/media/cna/files/en/competency_framework_2010_e.pdf.
Registered Psychiatric Nurse Regulators of Canada adopted by the College of Registered Psychiatric Nurses of Alberta (2014). Registered Psychiatric Nurse Entry-level Competencies
College of Registered Psychiatric Nurses of Alberta. (2013). Code of Ethics & Standards of Psychiatric Nursing Practice. Edmonton, AB: Author.
College and Association of Registered Nurses of Alberta, Restricted Activities Standards, April 2019 Edmonton, AB: Author
College and Association of Registered Nurses of Alberta, College of Licensed Practical Nurses of Alberta, & College of Registered Psychiatric Nurses of Alberta. (2010). Decision-making standards for nurses in the supervision of health-care aides. Edmonton, AB: Author.
College of Nurses of Ontario. (2009). Utilization of RNs and RPNs. Toronto, ON: Author.
Ellis, J.R., & Hartley, C.L. (2009). Managing and coordinating nursing care (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Government Organization Act, R.S.A. 2000, Sch. 7.1.
Health Professions Act, R.S.A. 2000, c. H-7.
Pharmacy and Drug Act, R.S.A. 2000, c. P-13.
Registered Psychiatric Nurses Profession Regulation, Alta. Reg. 231/2005 with amendments up to and including Alta. Reg.107/2021
Restricted Activities – Specific Clinical Examples
The health professions act (HPA) sets out for health professionals, scopes of practice, and indicates overlapping scopes of practice between the health professionals. The HPA gives several health professionals the authority to perform the same restricted activity. The context of practice, the setting, the client, and the clinical resources available will determine the extent to which a health professional will perform the restricted activity.
DISPENSE, SELL, COMPOUND
The CRPNA regulations state that CRPNA regulated members will be given authority to:
15(1)(D) to dispense, compound, provide for selling or sell a Schedule 1 drug or Schedule 2 drug.
Schedule 7.1 of the Government Organization Act (GOA) defines dispense as:
1(c) ‘dispense’ means (i) with respect to drugs, to provide a drug pursuant to a prescription for a person, but does not include the administration of a drug to a person; and sell as:
1(h) ‘sell’ includes:
(i) distribute, trade or barter for money or other valuable consideration,
(ii) distributing and giving away without expectation or hope of compensation or reward,
(iii) keeping for sale, and
(iv) offering for sale.
Section 15(2) of the CRPNA regulations places limits on the interpretation of ‘sell’ based on the above definition.
15(2) Despite subsection (1)(d), a regulated member registered on any category of the regulated members register who is performing the restricted activity described in that subsection shall not distribute, trade, or barter for money or valuable consideration, or keep for sale or offer for sale a Schedule 1 drug or a Schedule 2 drug but may distribute or give away a Schedule 1 drug or a Schedule 2 drug without expectation or hope of compensation or reward.
The authority to perform the restricted activity of dispensing and selling does not mean that regulated members will now be able to dispense or sell medications in the same manner as would pharmacists. It will, however, provide flexibility to meet client needs where a pharmacist is unavailable. Situations where this authority might be needed include, but are not limited to:
- provision of partial doses of a medication or a full prescription in a small rural emergency or where a pharmacy is not available;
- providing birth control pills or the “morning after” pill in a family planning clinic;
- providing medication for a client who is leaving a health-care facility on a pass for a limited time period when a pharmacist is not available to do so; and
- providing medications or a full prescription to treat sexually transmitted infections according to protocols in a STD clinic.
In applying the standards outlined in this document the following must be considered:
- Is there a pharmacist available?
- If there is no pharmacist, is this medication or practice necessary to meet the needs of clients or vulnerable populations?
- Do the regulated members have the knowledge and skill to appropriately dispense the medication?
In dispensing a medication there are 6 major issues to consider:
- appropriateness of the prescription
- dispensing procedures to ensure the integrity of the drug distribution system
- labeling the drug correctly
- documentation of the dispensing
- client education
- storage of the drugs
The Alberta College of Pharmacy has developed Standards of Practice for dispensing. They are available on their website (www.abpharmacy.ca) under the ‘Resource Centre’ tab. In any practice area where regulated members will be dispensing medications, the standards of practice developed by the Alberta College of Pharmacy are to be followed. The Alberta College of Pharmacy or a pharmacist must be involved in establishing the infrastructure, policies, and procedures in those specific situations where it is appropriate for regulated members to dispense medications. This will assist in ensuring the integrity of the drug distribution system, client safety and quality control.
The definition of ‘compound’ in the GOA is as follows:
1(b) “compound” means to mix together 2 or more ingredients of which at least one is a drug for the purposes of dispensing a drug or drugs.
There are instances in nursing practice where regulated members of CRPNA might engage in compounding where two ingredients are mixed, one of which is a drug for the purposes of dispensing.
Examples may include:
- mixing lidocaine and Maalox for a client to take home for relief of pain;
- crushing tablets for pediatric clients and mixing them with strawberry syrup for administration at home; and
- mixing two types of insulin and leaving the syringes with the client for self-administration.
In each of these examples, the regulated member is mixing two drugs and giving it to the client for the purposes of self-administration by the client at a later time.
The regulated member is mixing commercially available products. A commercially available product is defined by pharmacists as:
A pharmaceutical product authorized for use in Canada by the Health Protection Branch of Health and Welfare Canada, and having received a Notice of compliance, has been assigned a Drug Identification Number (DIN) and marketed in Canada. (Canadian Society of Hospital Pharmacists, 2001).
The mixing of pharmaceutical products of all dosage forms, oral liquid or solid, parenteral, and topical often affects the storage requirements, stability and, thus, the efficacy of the product. Consultation with a pharmacist and/or published references is encouraged if the nurse has not prepared the compound in the past and is required for any compounds that will be stored beyond 24 hours.
Reducing Dislocation of Joints
CRPNA regulations provide authority for regulated members to:
(4) A regulated member may perform the restricted activity of reducing a dislocation of a joint with the consent of and under the supervision of a regulated member of another college if the Council of that college, by regulation, authorizes a regulated member under Schedule 25 to the Act to perform that restricted activity under the supervision of its regulated members.
Cutting Body Tissue, Performing Surgical or Other Invasive Procedures
CRPNA regulations authorize regulated members to:
15(1)(a) to cut a body tissue, to administer anything by an invasive procedure on body tissue or to perform surgical or other invasive procedures on body tissue below the dermis or the mucous membrane.
This is a very broad restricted activity that could include a wide range of interventions. It is not intended to allow regulated members to perform surgery but is intended to allow for a variety of interventions, such as injections, deep wound debridement, medicated tube feedings and establishing an IV line, provided the standards outlined in this document are followed and applied appropriately.
Exceptions to Restricted Activities
Section 2 of Schedule 7.1 of GOA identifies the following as not being restricted activities:
a. activities of daily living, whether performed by the individual or by a surrogate on the individual's behalf
b. giving information and providing advice with the intent of enhancing personal development, providing emotional support, or promoting spiritual growth of individuals, couples, families, and groups
c. drawing venous blood
In addition, Schedule 7.1 identifies those situations in which a health-care aide might perform a restricted activity or an activity of daily living. CRPNA, in partnership with the College of Licensed Practical Nurses of Alberta (CLPNA) and the College and Association of Registered Nurses of Alberta (CARNA), has developed the document Decision-Making Standards for Nurses in the Supervision of Health-Care Aides (2010) to provide guidance for regulated members who work with health-care aides.
Students
17(1) A student who is enrolled in a psychiatric nursing program approved by the Council and is receiving training in providing restricted activities is permitted to perform the restricted activities set out in section 15 under the supervision of a regulated member registered on the registered psychiatric nurse register.
(2) Regulated members may supervise students of another profession that provides health services in the provision of restricted activities that are authorized for members of both professions and for the student.
(3) A regulated member who supervises a student must
(a) be authorized to perform the restricted activity that is being supervised,
(b) be on-site with the student while the student is performing the restricted activity, and
(c) be available for consultation and to assist the student in performing the restricted activity as required.
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