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Good News - Rn Can Soon Prescribe And Diagnose In Ontario!

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Hooray, more people who will over-prescribe unnecessary medications! That's going to help so much with quality and cost of healthcare!

 

 

(To be clear, the main offenders here are physicians, who despite being specifically trained to diagnose and treat conditions, give so many unhelpful or harmful prescriptions... why we need RNs to do more of what physicians do too much of already just completely baffles me)

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Does this mean Family doctors and nurses have same authorities now 

Why be  a physician when nurses can do same things

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Does this mean Family doctors and nurses have same authorities now 

Why be  a physician when nurses can do same things

 

In fairness, the exact scope of RN diagnosis and prescribing still needs to be clarified by the nurses' college, and I doubt they're going to endorse a scope of practice anywhere near that of an FP. Still, it's creep in that direction without a clear purpose or benefit for patients.

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This hopefully will be isolated in onterrible.

If Pharmacists, people who know the most about drugs, don't even have prescribing rights - why is it being given to RNs?  Unless its a very specific scope, i just dont see how its a good idea.    Many physicians are already terrible and they supposedly have far more training in medications and prescribing.

Dentiste, palefire, Clapton and 3 others like this

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In fairness, the exact scope of RN diagnosis and prescribing still needs to be clarified by the nurses' college, and I doubt they're going to endorse a scope of practice anywhere near that of an FP. Still, it's creep in that direction without a clear purpose or benefit for patients.

 

I agree with the statement. They also have to make the distinction between RN's and NP's scope of practice if both are now prescribing and ordering diagnostic tests. It's clear that the RN equivalent in the UK has been prescribing for the past 15 years, and doctors still continue to exist in their healthcare system lol. 

 

As a positive, however, I think/hope it'll be helpful for future residents on this forums when we're on call. When I was a RN, I felt HORRIBLE calling the busy resident on-call at 3am just to get a verbal order for acetaminophen or ibuprofen. And on top of that if they are in the ER for a consult or stuck in the OR you have to wait and delay giving tylenol... Like what? It's also just more paperwork for them to sign as well.

 

So yes, I definitely see how it can feel to be a little bit invasive and daunting for soon to be MD's, like my self, and freshly minted MD's, but I do see a happy medium in this situation. 

 

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This hopefully will be isolated in onterrible.

 

If Pharmacists, people who know the most about drugs, don't even have prescribing rights - why is it being given to RNs?  Unless its a very specific scope, i just dont see how its a good idea.    Many physicians are already terrible and they supposedly have far more training in medications and prescribing.

 

Well according to framework by CNA on RN prescribing (April 2015): https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/cna-rn-prescribing-framework_e.pdf?la=en

 

There are other provinces who are on top of the ball (Appendix A):

 

Alberta • The College and Association of Registered Nurses of Alberta is developing and finalizing standards for RN prescribing. RNs will be able to prescribe in specific settings for particular patient populations/needs.

 

British Columbia • The College of Registered Nurses of British Columbia is leading the use of certified practice: RNs in certified practice have the authority to independently administer and dispense certain drugs that normally require a prescription or an order. Certified practice categories include contraceptive management, sexually transmitted infections, remote practice and RN First Call (rural practice).

 

Manitoba • The College of Registered Nurses of Manitoba is developing a RN prescribing role (currently referred to as “RN authorized prescriber”) that will be linked to 

specific practice settings and specialties (e.g., primary care, public health, reproductive health).

 

New Brunswick • RN prescribing not in place.

 

Newfoundland and Labrador • RNs working in specific areas of the province may (under authorization through their employer) provide patients with selected medications in specific situations.

 

Nova Scotia • RN prescribing not in place.
 
Northwest Territories • RN prescribing not in place.
 
Nunavut • RN prescribing not in place. 

 

Ontario • RN prescribing not currently in place.

 

Prince Edward Island • RN prescribing not in place.

 

Quebec • The Ordre des infirmières et infirmiers du Québec is in the process of implementing RN prescribing for specific situations and patient needs.

 

Saskatchewan • The Saskatchewan Registered Nurses’ Association is in the midst of implementing “additional authorized practice.” This is somewhat similar to the certified practice approach in British Columbia.

 

Yukon • RN prescribing not in place. 

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I agree with the statement. They also have to make the distinction between RN's and NP's scope of practice if both are now prescribing and ordering diagnostic tests. It's clear that the RN equivalent in the UK has been prescribing for the past 15 years, and doctors still continue to exist in their healthcare system lol. 

 

As a positive, however, I think/hope it'll be helpful for future residents on this forums when we're on call. When I was a RN, I felt HORRIBLE calling the busy resident on-call at 3am just to get a verbal order for acetaminophen or ibuprofen. And on top of that if they are in the ER for a consult or stuck in the OR you have to wait and delay giving tylenol... Like what? It's also just more paperwork for them to sign as well.

 

So yes, I definitely see how it can feel to be a little bit invasive and daunting for soon to be MD's, like my self, and freshly minted MD's, but I do see a happy medium in this situation. 

 

 

 

That positive you describe is where I get worried. I've already had to say "no" to requests that are as seemingly simple as an RN asking for something like ibuprofen, and I'm just a graduating medical student. Yes, it sucks to get paged at 3 am for what should be obvious requests, but I'd rather get that page than find out a patient got the medication after the fact, especially when there are ways to minimize those 3 am pages that we don't use as often as we could.

 

I'm not worried in the slightest about these changes affecting my job prospects, or those of students coming after me. The issue here to me isn't a turf war between physicians and RNs - having worked in healthcare before medical school, I've been on both sides of those turf wars and find them pretty ridiculous. What I worry about is patient care. We over-prescribe like crazy in Canada and getting current prescribers to change their habits is very difficult. Adding thousands of more prescribers can only exacerbate these issues, while adding on extra issues regarding standardization of interventions, continuity of care, and unclear roles to patients. There are already ways to allow RNs to give medications under a narrow set of conditions that sidestep these issues, if that's the goal - independent prescribing isn't necessary to achieve that objective.

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That positive you describe is where I get worried. I've already had to say "no" to requests that are as seemingly simple as an RN asking for something like ibuprofen, and I'm just a graduating medical student. Yes, it sucks to get paged at 3 am for what should be obvious requests, but I'd rather get that page than find out a patient got the medication after the fact, especially when there are ways to minimize those 3 am pages that we don't use as often as we could.

 

I'm not worried in the slightest about these changes affecting my job prospects, or those of students coming after me. The issue here to me isn't a turf war between physicians and RNs - having worked in healthcare before medical school, I've been on both sides of those turf wars and find them pretty ridiculous. What I worry about is patient care. We over-prescribe like crazy in Canada and getting current prescribers to change their habits is very difficult. Adding thousands of more prescribers can only exacerbate these issues, while adding on extra issues regarding standardization of interventions, continuity of care, and unclear roles to patients. There are already ways to allow RNs to give medications under a narrow set of conditions that sidestep these issues, if that's the goal - independent prescribing isn't necessary to achieve that objective.

 

 

 

We aren't discussing current level of education of RN's. We are discussing RN's who will have received additional training to be able to prescribe the select number of medications.

 

And I do agree we over prescribe in Canada for certain medications. But you are thinking of "independent prescribing" as a radical change, where a RN would suddenly be able to order an MRI and fentanyl. I was not, and am not, suggesting that RN's should EVER be allowed to prescribe drugs like fentanyl or hydrochlorothiazide, and I HIGHLY doubt that is the change that we are currently talking about.

 

And like I stated before, they cannot broaden the scope of prescribing and diagnosing to the level of a NP, because that would be counterintuitive and make NP's and their training redundant. However, I strongly believe that there are certain situations, regardless of the time of the day, that a RN with additional training and experience would be qualified enough to prescribe SOME medications or order SOME diagnostic tests.

 

Like you alluded to, we already see this among ER nurses who have standing orders and protocols that allow them to order CBC's, lytes, + other tests as well as administer drugs such as 81mg ASA or nebuterol.

 

But prescribing medications and ordering tests is even simpler than ASA and CBC. It even includes OTC topical ointments like voltaren, low percentage zinc oxide cream for diaper rash, or specimen collection for suspected c.diff. I'm not saying that there aren't situations where voltaren and zinc oxide cream is contraindicated with other medications/treatment, but if we can educate RN's these contraindications, and teach specific situations/criterias where it is okay to prescribe voltaren, zinc oxide, and order a test for c.diff, I think that would make both the patient's experience in the hospital and the resident physician's job better. 

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What Ralk is probably alluding to is the slippery slope.

First it starts off as health-care providers getting expanded scope for rural practice, because there aren't many docs there. But then after a short time, other HCPs say "hmm we can do xyz in rural Alberta, why cant we do that in Calgary?"

Look to the US as a prime example.   Naturopaths in many states function in the same potential scope as Family Medicine docs, but without even a fraction of the training or competency. 

Physician Assistants who generally work under physicians, are trying to get independent scope practice as well.  Sure the PA whos 10 years out is competent, but then to apply the same scope to the fresh PA grad is bad. Hospital admins LOVE this sort of thing, because they can provide the same service for X dollars, but pay someone less to do it.  Then you get some  poor quality observational studies being pumped out by the HCP groups "Look our quality of care is just the same, if not better than those heartless, unempathic doctors! And we cost less!"

Everyone wants to be a doctor, but doesn't want the ultimate responsibility/liability.

I agree that for specific use cases that RN or any other HCP prescribing is a good thing - but what worries me is when people use that as a means to push scope boundaries.

 

I don't care about turf boundaries really, I do care that someone who's going to have expanded scope be competent, or at least go through similar training that others with existent scope had to go to achieve that. 

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We aren't discussing current level of education of RN's. We are discussing RN's who will have received additional training to be able to prescribe the select number of medications.

 

And I do agree we over prescribe in Canada for certain medications. But you are thinking of "independent prescribing" as a radical change, where a RN would suddenly be able to order an MRI and fentanyl. I was not, and am not, suggesting that RN's should EVER be allowed to prescribe drugs like fentanyl or hydrochlorothiazide, and I HIGHLY doubt that is the change that we are currently talking about.

 

And like I stated before, they cannot broaden the scope of prescribing and diagnosing to the level of a NP, because that would be counterintuitive and make NP's and their training redundant. However, I strongly believe that there are certain situations, regardless of the time of the day, that a RN with additional training and experience would be qualified enough to prescribe SOME medications or order SOME diagnostic tests.

 

Like you alluded to, we already see this among ER nurses who have standing orders and protocols that allow them to order CBC's, lytes, + other tests as well as administer drugs such as 81mg ASA or nebuterol.

 

But prescribing medications and ordering tests is even simpler than ASA and CBC. It even includes OTC topical ointments like voltaren, low percentage zinc oxide cream for diaper rash, or specimen collection for suspected c.diff. I'm not saying that there aren't situations where voltaren and zinc oxide cream is contraindicated with other medications/treatment, but if we can educate RN's these contraindications, and teach specific situations/criterias where it is okay to prescribe voltaren, zinc oxide, and order a test for c.diff, I think that would make both the patient's experience in the hospital and the resident physician's job better. 

 

I've also already had issues (multiple ones) with improper requests for C.Diff testing, again, as a medical student...

 

My point isn't that RN's can't be trusted with diagnosis or prescription, especially in limited forms, given appropriate training. My point is that diagnosis and prescription are never as simple as they're made out to be, even in seemingly simple situations, and even well-trained individuals get it wrong all the time. The more people who can prescribe, the more can prescribe inappropriately. This expansion means over 100,000 individuals could get a degree of prescribing power, in a wide variety of working situations. Even assuming that the scope of prescription is appropriately limited and the training provided is right up to the level of a physician in those situations, that's a lot of people who can now make the same errors physicians (and other prescribers) frequently make.

 

Due to the role RNs serve within the healthcare team, it also removes a check against improper prescribing. Currently, when an RN notices a problem that might require intervention, they have to decide that the intervention might be worth pursuing, then contact the physician or NP to consider that intervention. Yes, it's clunky and seems inefficient, but it provides a level of protection for patients. That protection also works in the other direction - I can't say how many times an RN has caught an ill-advised prescription that I suggested or a physician on my team ordered, including on seemingly low-risk scripts. That physicians don't frequently administer their own interventions means another set of eyes reviewing any of their prescriptions. RNs who can prescribe and simultaneously administer their own interventions don't have that natural check against their own actions. Such a decrease in checks and balances increases the likelihood of medical errors, even if RN competency with prescribing was brought up to the exact same level of current prescribers.

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Hard to comment until we know what drugs/conditions and under what circumstances. To be honest there are underserved rural areas where RNs that could prescribe basic stuff for common standardized conditions could do a lot of good. (Think amoxicillin for otitis media way up north.)

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The slippery slope argument is a philosophical phallacy (edit fallacy haha!). It suggests that we cannot be trusted to draw the line in the sand. It happens all the time, we have lines in the slope everywhere.

 

Should every line be negotiated? Absolutely. Changed? No. But held for fear of not being to draw a new on? Definitely not. The slippery slope is a poor argument.

 

What we do need to decide, is who should be at the table? Who makes the decision? Where is the line? Where should it go? How do we maintain it? When should we agree to reconvene and revaluate the line? The concern is that we fail to answer those questions appropriately, not that it can't be done.

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The slippery slope argument is a philosophical phallacy. It suggests that we cannot be trusted to draw the line in the sand. It happens all the time, we have lines in the slope everywhere.

 

Should every line be negotiated? Absolutely. Changed? No. But held for fear of not being to draw a new on? Definitely not. The slippery slope is a poor argument.

 

What we do need to decide, is who should be at the table? Who makes the decision? Where is the line? Where should it go? How do we maintain it? When should we agree to reconvene and revaluate the line? The concern is that we fail to answer those questions appropriately, not that it can't be done.

The slippery slope i agree can be a poor argument in many circumstances, but sorry - the US is a perfect example of the slippery slope argument going wrong in medicine.

 

And no, many involved in these processes cannot be trusted to draw the line. The physician group as a cohort, is and has been historically poor at managing these things. Why? Because doctors are too busy doing work to have as much time to lobby and protest on these sorts of things. Not specifically the situation of this OP, in general.  Doctors don't have unions in the same sense as other HCPs. 

 

While i appreciate your comment fully, it doesn't take into account the natural greed and desires of various powerful unions, businesses and lobbyists. 

 

 

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The next logical step is, "We're doing more work now, and have expanded scope - so we should be paid more".   This obviously isn't an extreme example, and is unlikely to be anything super serious that would get people up in arms, but it could be. Probably not, but it is hard to say one way or another without the full details of the plan.

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Why shouldn't nurses be paid more if they have more responsibility?

They should be.

 

But if prescribing/diagnosing went the extreme(very unlikely) route of being parralleled to Family Medicine, well, that would be trouble for people who went that route.

 

There's X amount of healthcare dollars to be divided up.

 

(Just so we're clear, I don't actually think any of this will be an issue, just providing hypotheticals :) )

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The slippery slope argument is a philosophical phallacy. It suggests that we cannot be trusted to draw the line in the sand. It happens all the time, we have lines in the slope everywhere.

 

Should every line be negotiated? Absolutely. Changed? No. But held for fear of not being to draw a new on? Definitely not. The slippery slope is a poor argument.

 

What we do need to decide, is who should be at the table? Who makes the decision? Where is the line? Where should it go? How do we maintain it? When should we agree to reconvene and revaluate the line? The concern is that we fail to answer those questions appropriately, not that it can't be done.

 

Hehe. Phallacy. Sorry, couldn't resist.

 

To be clear though, a slippery slope argument is only a fallacy if presented as a definitive proof rather than a probablistic argument. As JohnGrisham says, there is evidence of a snowballing effect in other jurisdictions, in no small part because our politicians are swayed by political pressure as much if not more so than they are by rational arguments. We're seeing that play out right now with naturopaths, who shouldn't be anywhere near prescribing, gaining that ability and pushing for even more rights. It's entirely possible that the line gets drawn at a logical point, but comparable situations and historical examples indicate that it probably won't.

 

Additionally, the slippery slope fallacy only applies if the current step under consideration is benign or positive - as I've tried to lay out, there are reasons that this is a potentially negative decision in and of itself, even if no further steps are taken.

 

Why shouldn't nurses be paid more if they have more responsibility?

 

Because it eliminates a major reason for using them in the first place - cost. It becomes a bait-and-switch, using the allure of lower costs to justify the expansion of responsibilities, then using that expansion of responsibilities to argue for higher pay. In the end, they cost as much as the groups they were replacing on a per-unit of work basis, but now with added complexity in the system in the form of blurred roles and responsibilities.

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That positive you describe is where I get worried. I've already had to say "no" to requests that are as seemingly simple as an RN asking for something like ibuprofen, and I'm just a graduating medical student

 

 

 

Yeah, sometimes simple things can be overlooked....for example NSAIDs and CHF/AKI are not friends and ibuprofen seems like a simple enough thing. some nurses i've worked with were perplexed when we denied advil prescriptions for those reasons. few things are TRULY innocuous. 

 

except for melatonin

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I definitely can understand having concern...but I have reservations about including the slippery slope as a counter augment. Rather we should identify the actual concerns and the limits that need to be met.

 

Example

Concerns RN's gain too much scope for their four year degrees.

Concerns that unregulated healthcare providers take on prescribing privileges.

Concerns that RN wages snowball and limit resources.

Concerns that these lead to poor patient outcomes.

 

People use the slippery slope argument against

 

Gay marriage

Abortion

Active euthanasia

Etc

 

I feel to engage the slippery slope argument and not have it be a fallacy the onus is on you to delineate the logical, and likely steps that lead to the destination proposed. And to be able to defend how this destination is unavoidable.

 

I can appreciate that history will demonstrate many salient examples of the line being drawn incorrectly, but I would challenge you then to define that these are more often examples of a "slippery slope" wherein one decision makes the next more likely and so forth, until the distinction that was once made is no longer in sight. I say this, because often it is also that the line is incorrectly placed initially. I would argue that increasingly we see evidence that as we revisit concepts we refine our understanding and arrive some-where more reasonable then initially.

 

RN's take anatomy, physiology, pathophysiology, and pharmacology. Naturopaths for example often do not. They are also not licensed, nor do they agree to engage in evidence based practice. We have a lot of commonalities between MD's and RN's to find common ground with, and few for naturopaths. With such distinctions there seems to be good basis for how such limits could be made relating to who can prescribe, and what they can prescribe.

 

For as much as there is that RN's learn through education, there is more they don't. Thus we have many places to exact definite limits on what can be prescribed by who.

 

I guess I would ask, what is the slippery slope? What are the plausible next steps that are uncontrollable and unavoidable. Where does the lack of decision-making, and control, factor in that lead to RN's becoming family doctors? Or to naturopaths prescribing medications. Why are limits unavoidable?

 

One good reason for RN's having the ability to prescribe - wait times, and physician load.

Now my take is that, sure RN's could (in limited settings, with limited drugs) have prescribing privileges. They should not be paid more for this. Really, we should have RN's doing the work they were trained to do, and have LPN's doing the work they were trained to do, and NA's....so forth.

 

I would propose having less RN's more LPN's and even more NA's. RN's have been engaged in a turf war that sees them clinging onto tasks like bed baths, but then demanding the privilege to do higher level tasks. At 100 000k a year in Alberta for example for a yearly RN wage, something has got to give.

 

I do think we get fairly compensated, but also think we spend a lot of time doing tasks that don't require the skill set of an RN. To be fair, I'm about to commence training as a physician, and maybe with new perspectives I will feel different about RN's with prescribing privileges. I do know I feel like physicians could have their hands freed in SOME situations and patients could have expedited care.

 

While I talk about drawing the line. I don't know where it is. But I do believe it can be determined, and that patients and the system generally would benefit from revisiting some of these things. This of course could just be a demonstration of my naivety.

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Many of ralk's arguments do resonate: the idea of increased system level checking, the potential for more overprescription, the potential complications, etc..  

 

It's just that not so long ago, people would have never believed NP or PA (Advanced Practice Clinicians) to be able to provide the same level of care as a physician.  Yet, a recent study that I saw basically states that for "low value health care", APCs do indeed provide an equivalent level of care (link).

 

Of course the evolution of the the roles didn't happen overnight, and proceeded in small incremental steps.  I just don't see how for RNs if greater competency can be achieved, that's really a negative - but perhaps, this is too much of a change and that the negatives do outweigh the potential gains.

 

I do understand the "turf war" concept but just feel health care as a whole should be forward looking rather than fixed in a static image of today's practice models.  But, of course with health care, almost more than anything else, change requires the greatest prudence and care.  

 

While I understand JohnGrisham's point concerning the slippery slope in the US, I feel this also reflects American culture.  Americans (esp current administration for instance) are somewhat anti-regulatory, so I'm not surprised that naturopaths have greater scope, for example.  And I was also under the impression that the AMA was powerful voice, but I'm far from an expert on US health care.       

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