Oct 07, 2019
Nurse practitioners in Ontario gaining prescriptive authority
Take away messages:
- Nurse practitioners (NPs) require additional educational support beyond regulatory requirements for safe and efficacious prescribing of controlled drugs and substances (CDS).
- NPs specializing in pain management are well positioned to provide leadership and mentoring for knowledge development.
- Educational resources to support safe and effective CDS prescribing should be multifaceted.
In April 2017, Ontario’s Ministry of Health and Long-Term Care and the College of Nurses of Ontario (CNO) expanded the scope of practice of Nurse Practitioners (NPs) to include the prescribing of controlled drugs and substances (CDS). Prescriptive authority is a fundamental component of professional autonomy and quality patient care.
Unity Health Toronto, St. Michael’s site, is an adult trauma centre and a hub for advanced specialties such as neurosurgery and cardiovascular care. All 50 NPs at St. Michael’s Hospital (SMH) completed the CNO-mandated education requirement and were able to practise without restrictions. The program was an accredited, self-directed online course with a primary care focus and took participants 6 to 20 hours to complete.
Despite fulfilling educational requirements for practice, many NPs reported they lacked confidence in prescribing CDS, particularly in the context of increasing scrutiny around opioid use. This experience is not uncommon in other jurisdictions when prescribing of CDS is new to NP practice (Kaplan, Brown, & Donahue, 2010). NPs at SMH also felt that this mandatory education did not provide adequate preparation for prescribing. Therefore, NPs at SMH requested additional guidance and resources to prescribe CDS safely and effectively.
As acute pain management NPs, our specialty knowledge positioned us to lead an educational initiative to support NPs in safe and effective prescribing of CDS. By sharing our initiative, our intention is to provide guidance in supporting NPs to prescribe CDS competently and confidently.
Our initiative took place over the course of one year, beginning in March 2017, a month before the legislative changes came into effect. Fifty NPs in various practice settings, including primary care, cardiovascular, neurosurgery, and outpatient clinics, were polled using an online survey to assess learning needs.
Survey questions focused on three main themes: how NPs would adopt the prescription of CDS in their clinical practice; the type of CDS that could be prescribed; and confidence level with these medications. In addition, questions were asked regarding comfort level in performing a comprehensive pain assessment and using multimodal analgesia.
The survey results indicated that NPs would be most commonly prescribing CDS for acute pain, chronic pain, and anxiolysis (see Figure 1). As illustrated in Figure 2 and FIgure 3, the majority of NPs were not comfortable with comprehensive pain assessments or using multimodal strategies, including prescribing opioids for pain management.
Survey data: NP prescribing patterns
Survey results: Majority of NPs not comfortable with multimodal prescribing
Survey results: NP comfort levels with pain assessment and management
The educational approach was multidimensional and provided a number of strategies including a review of relevant guidelines, didactic and case presentations, individual coaching and mentorship, a repository of resources, and discharge instructions for patients going home with an opioid prescription (see Figure 4).
Preferred educational resources
We organized seven educational sessions to be delivered by subject experts. In keeping with best practices in education delivery, a problem-based learning approach was utilized. However, there was often foundational knowledge that was important to communicate in a didactic format.
Topics were chosen based on learning needs identified in the survey results. For example, the majority of participants were not confident in prescribing cannabinoids, and therefore, an educational session by a chronic pain physician with expertise in cannabinoids was organized. Only 11% of NPs were comfortable treating acute-on-chronic pain, so a session on this is planned in upcoming months. This was the agenda for the hour-long educational sessions:
- Acute pain management and safe opioid prescribing, including an overview of available guidelines (US and Canadian), comprehensive pain assessment, opioid titration and rotation, multimodal management, and opioid risk assessment; 2 sessions
- CDS in addiction medicine—review of suboxone and methadone maintenance, and pain management in opioid-tolerant patients; 2 sessions
- Cannabinoids—chronic pain anesthesiologist
- CDS in palliative care—NP in palliative care
In addition to these educational sessions, our needs survey indicated that in order to build confidence in prescribing, NPs preferred the opportunity to review cases with an expert. NPs in the acute pain service provide formal and informal consultation, including decision support for opioid increases, opioid rotation, and management of opioid-related side effects. Prescriptive authority for NPs created an increase in requests for consultation for discharge prescription recommendations and approaches to multimodal analgesia.
An online post-educational survey was sent out to all NPs. Unfortunately, the evaluation was not linked to session attendees to provide a more robust evaluation of the program. Collectively, the feedback that we did receive indicated that the sessions were helpful and supportive in building knowledge and confidence. Future sessions will connect participants with post-session evaluations.
One final educational session is planned on acute-on-chronic pain. Repeat educational sessions will be provided on an ongoing basis as indicated and based on emerging new evidence with respect to CDS and, specifically, opioid prescribing. In keeping with ongoing continuing education, our initiative to provide acute pain education to NP students rotating through our organization has been well received.
We will continue to be available for consultation, formal or informal, to support NPs with their relatively new prescriptive authority. Additionally, education and educational resources will be offered to multidisciplinary teams for safe and effective prescribing of CDS.
The legislative barrier to prescribing of CDS for NPs has been removed, and NPs now have the authority to practise to full scope. Competence to prescribe CDS is designated by the College of Nurses of Ontario, with completion of a mandatory, college-approved program. This, however, did not provide NPs in our organization with the confidence to prescribe CDS safely and effectively. The literature offers evidence of similar experience in other practice settings across Canada and the US. Given that NPs historically did not have education that included CDS until recently, this is understandable. In addition, it is appropriate for experts in the field of acute pain management, who have a unique skill set in opioid management, to lead such initiative.
This educational initiative provides an example and model for other organizations to follow, not only for NPs but also for all prescribers of CDS, in providing evidence-based, competent, safe, and timely care to patients requiring CDS, particularly in the context of the opioid crisis and the increase in opioid use disorder.
Kaplan, L., Brown, M. A., & Donahue, J. S. (2010). Prescribing controlled substances: How NPs in Washington are making a difference. Nurse Practitioner, 35(5), 47–53.
Ambrose, M. A., & Tarlier, D. S. (2013). Nurse practitioners and controlled substances prescriptive authority: Improving access to care. Nursing Leadership, 26(1), 58–69.
College of Nurses of Ontario (CNO). (2019). Q&As: Controlled substances education requirement.
Health Quality Ontario. (2018) Opioid prescribing for acute pain: care for people 15 years of age and older. Quality standard.
Moghabghab, R., Hamilton-Jones, M., Jabbour, R., McNabb, A., & Tilley, E. (2016). Nurse practitioner practice and controlled substances in Ontario: Current practice and future intent. Nursing Leadership, 29(3), 93–105.