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Answering your questions about RN scope of practice standards
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 Acting within autonomous scope of practice

What's the difference between acting within autonomous scope of practice” and what we were doing before? What does autonomous mean?

Only the language of the nursing standard has changed—not your nursing practice. We’ve updated the language used in the standard to reflect that registered nurses have an autonomous scope of practice.

‘Autonomous’ means that registered nurses have the self-directed authority, assume sole accountability and responsibility, and have the individual competence, to carry out certain nursing activities.

Nurses can self-initiate activities they are educated and authorized to perform (under the RN Regulation), to promote wellness, improve or resolve a condition, or prevent illness.

Not restricted and Section 6 restricted activities fall within autonomous scope of practice for registered nurses.  Those with certified practice may also carry out Section 8 restricted activities.  

See examples of acting within in autonomous scope of practice

I was allowed to insert a urinary catheter for bladder retention without an order in my previous practice area. I have the competence. Can I do this in my current worksite?

You may have the competence to diagnose bladder retention and treat it with urinary catheterization however, this doesn’t necessarily mean you can do this without an order at any work site. Your organization, agency or unit may restrict the activities you are allowed to carry out within your autonomous scope of practice. Check your organization’s policies.

There are a number of controls on nursing practice that impact what activities you can carry out, as well as where and when you can carry them out. The RN Regulation sets out a fairly broad scope of nursing practice. CRNBC limits this scope further by setting standards, limits and conditions on nursing activities. Your organization’s polices may further restrict or limit your practice in that organization or a particular unit.

See the Standards for Acting within Autonomous Scope of Practice for more information and guidance.

What is the difference between a client-specific order and a Registered Nurse Initiated Activity (RNIA)?

An order is an instruction or authorization given by a regulated health professional to provide care for a specific client. Registered nurses require orders to carry out activities within Section 7 of the RN Regulation. When nurses carry out activities by acting with orders, they meet the Standards for Acting with Client-specific Orders.

In contrast, an RNIA is a type of decision support tool (DST), supporting nurse-initiated activities. DSTs are evidence-based documents that support nurses to provide standardized, consistent and safe patient care when acting within their autonomous scope of practice.

These tools guide nurses in assessing, diagnosing and treating and/or preventing specific client conditions, illnesses or injuries, within their autonomous scope and individual competence. Other terms for DSTs include:

  • clinical practice standards and procedures
  • clinical decision support tools (CDSTs)
  • algorithms
  • protocols

These tools set the organizational policy and procedure for performing activities, congruent with the standards, limits and conditions established by the CRNBC. When nurses carry out activities following RNIAs, they meet Standards for Acting with Autonomous Scope of Practice, including assuming sole accountability and responsibility for their decisions and actions.

 Acting with client-specific orders

I've heard that nurses can carry out orders from PTs, OTs, dietitians and other RNs. What do I need to know about this?

The revised Standards for Acting with Client-specific Orders authorize nurses to act on orders from non-listed health professionals - regulated health professionals not listed in the RN Regulation. These include physiotherapists, occupational therapists, dietitians, psychologists, registered psychiatric nurses and other registered nurses. It's important to know that:

  • Nurses only act on client-specific orders from non-listed health professionals for activities within their autonomous scope of practice and individual competence
  • Additional organizational supports, processes and resources are required before nurses can act on orders from non-listed health professionals

Nurses are part of interdisciplinary teams. Other health professionals likely already provide direction for client care through recommendations and care planning. If current interdisciplinary team and care-planning processes effectively meet client needs, your organization may choose not to introduce processes for RNs to give orders or act on orders given by non-listed health professionals. They may also choose to implement in specific practice areas only.

If a listed health professional, such as an NP, physician or RN(C), gives an order for an activity within my autonomous scope and I disagree with it, can I change or cancel the order? What if it’s a non-listed health professional such as PT, OT

If you disagree with a client-specific order for an activity that is within your autonomous scope of practice and individual competence, you can change or cancel it, regardless of whether the ordering professional is listed or non-listed.  However, you’ll need to determine if it’s appropriate for you to do so. This includes communicating and collaborating with the ordering professional (or their delegate) and the health care team. You will need to share the rationale for your decision. For instance if it doesn’t seem evidenced-based or the order is no longer appropriate because the client’s condition has changed.

Nurses may not change or cancel a client-specific order given by a listed health professional when the activity is outside their autonomous scope of practice or the nurse’s individual competence. They may need to ‘hold’ the order until they contact the ordering health professional if there are questions about the order or the appropriateness of the order for that client.

If you decide to change or cancel an order, you’ll need to follow the Standards for Acting within Autonomous Scope of Practice and/or Giving Client-specific Orders. You’ll be solely accountable for any changes that you make. It’s also important to aware of your role and responsibilities, including any agency restrictions, when acting within your autonomous scope of practice and changing or cancelling orders.

 Giving client-specific orders

As a registered nurse, who can I give a client-specific order to?

Client-specific orders are not ‘given to’ someone.  RNs give client-specific orders to meet client needs.  These client-specific orders are then acted upon by health professionals who determine if:

  • The activity is within their autonomous scope of practice to perform
  • Appropriate organizational supports are in place
  • They have the competence to carry out the activity

See the Standards for Giving Client-specific Orders for more information and guidance.

Who is ultimately responsible for a client-specific order? The registered nurse who writes the order or the nurse who carries out the activity?

Ultimate accountability and responsibility for the client-specific order lies with the ordering health professional. However, the nurse acting on the order is accountable and responsible for:

  • Ensuring the order is appropriate, clear and complete
  • Assessing the client to ensure their condition still warrants the activity
  • Taking appropriate action if the order does not seem to be evidence-based or consider client’s wishes/characteristics

When you give a client-specific order, you’re accountable for your decision to give the order and for evaluating client outcomes.  Unless you are in a supervisory position, you are not accountable or responsible for ensuring that the health professional carrying out the client-specific order is:

  • working within their scope of practice
  • competent to perform the activity

See the Standards for Giving Client-specific Orders for more information and guidance.

I’ve heard registered nurses are ‘listed’ in the LPN Regulation. What does this mean?

In the same way some health professionals (e.g., physicians, NPs, midwives, RN(C)s, etc.) are listed in the RN Regulation as authorized to give client-specific orders for activities within Section 7 of the RN Regulation,  RNs are listed in the LPN Regulation. In other words, RNs are one of the health professionals authorized to give client-specific orders for restricted activities in Section 7 of the LPN Regulation – activities requiring an order from a listed health professional.

Some of these restricted activities are within the RN autonomous scope of practice (Section 6 of the RN Regulation). RNs may give client-specific orders for activities within their autonomous scope of practice and individual competence.

For example, an LPN can carry out urinary catheterization with an order from a listed health professional. Within their autonomous scope of practice, an RN can diagnose urinary retention in the client and give a client-specific order for catheterization to treat it. Acting with this order, the LPN could carry out the catheterization.

If I give an order and later find out I’ve made an error, who is responsible? Just me, or the nurse who carried out the order too?

Every health professional is accountable and responsible for their decisions and actions. As the nurse giving the order, you would be professionally accountable for your error.

The nurse acting on the order is also professionally accountable if, given the circumstances, he or she should have recognized that carrying out the order, without questioning it further,  was not appropriate. For example, if you made an error in a medication dosage that a reasonable and careful nurse should have recognized before administering the medication.

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