Acting Within Autonomous Scope of Practice

Practice Standard for registered psychiatric nurses

BCCNM limits and conditions for registered psychiatric nurse: Acting within autonomous scope of practice

Introduction

The Registered Psychiatric Nurse: Acting within Autonomous Scope of Practice standards, limits, and conditions apply to registered psychiatric nurses when they are acting within autonomous scope of practice (without an order). These standards, limits, and conditions also apply to certified practice registered psychiatric nurses [RPN(C)s] when they are performing activities within their autonomous scope of practice (without an order) that are not within their certified practice designation.

Acting within autonomous scope of practice refers to registered psychiatric nurses:

Assuming accountability and responsibility for making decisions about client care, and
Performing activities that they are competent and allowed to perform without a client-specific order.

Registered psychiatric nurses are allowed, within their autonomous scope of practice to make a nursing diagnosis^[1] of a client condition^[2] that can be prevented, improved, ameliorated, or resolved through nursing activities. Autonomous scope of practice includes:

Restricted activities that do not require an order per the Nurses (Registered Psychiatric) Regulation and
Care or services that are not restricted activities, unless excluded from autonomous scope of practice (without an order) by any BCCNM standard, limit, or condition.

Registered psychiatric nurses may provide care or services to clients by acting within their autonomous scope of practice when the care or services are:

Within the registered psychiatric nurse's autonomous scope of practice (without an order),
Provided in alignment with BCCNM standards, limits, and conditions,
Allowed by organizational/employer policies, processes, and
Within the registered psychiatric nurse's individual competence.

Registered psychiatric nurses need to know when they are allowed to act within their autonomous scope of practice (without a client-specific order) and when a client-specific order is required before performing an activity. Registered psychiatric nurses follow the Registered Psychiatric Nurse: Acting with Client-specific Orders standards, limits, and conditions when performing activities that are not within their autonomous scope of practice.

Standards

1.	Registered psychiatric nurses are accountable and responsible when they make a decision that the client's condition^[3] would benefit from an activity and act within autonomous scope of practice to perform the activity.
2.	Registered psychiatric nurses acting within autonomous scope of practice ensure that the activity they will perform is:
	a.	Within the scope of practice for registered psychiatric nurses acting without a client-specific order as set out in the Nurses (Registered Psychiatric) Regulation,
	b.	Consistent with BCCNM’s standards of practice including standards, limits, and conditions,
	c.	Consistent with organizational/employer policies, processes, restrictions, and
	d.	Within the nurse’s individual competence.
3.	Registered psychiatric nurses acting within autonomous scope of practice ensure they have the competence to:
	a.	Make decisions about whether the client would benefit from the activity, having considered:
		i.	Potential risks to the client and how to minimize those risks,
		ii.	The benefits to the client,
		iii.	The predictability of outcomes of performing the activity, and
		iv.	Other relevant factors specific to the client or situation,
	b.	Carry out the activity safely and ethically, and
	c.	Safely manage the intended and unintended outcomes of performing the activity.
4.	Before performing an activity within autonomous scope of practice, registered psychiatric nurses consider applicable employer/organizational policies, processes, and resources, and other relevant human and system factors that may impact their ability to:
	a.	Perform the activity competently and safely within their practice setting, and
	b.	To manage intended and unintended outcomes of the activity.
5.	Registered psychiatric nurses perform advanced activities within their autonomous scope of practice only when they have obtained the additional education, training, and/or clinical experience needed to gain and maintain the competence to perform the activity safely.
6.	Registered psychiatric nurses acting within autonomous scope of practice identify the effect of their own values, beliefs, and experiences in decision-making, recognize potential conflicts, and take action for the needs of the client to be met.
7.	Registered psychiatric nurses acting within autonomous scope of practice use current evidence to support their decision-making and the activity to be performed.
8.	Registered psychiatric nurses acting within autonomous scope of practice follow a clinical decision-making process when they:
	a.	Assess the client’s health status,
	b.	Make a nursing diagnosis^[4]of a client condition that can be prevented, improved, ameliorated, or resolved through nursing activities,
	c.	Determine a plan of care,
	d.	Determine an activity to be performed,
	e.	Implement an activity to prevent, treat, or palliate an illness or injury and/or improve, ameliorate, or resolve a condition,
	f.	Change or cancel a client-specific order for activities within the nurse’s autonomous scope of practice,
	g.	Give a client-specific order,
	h.	Manage the intended and unintended consequences of carrying out the activity, or
	i.	Manage and evaluate the outcomes of the activity.
9.	Registered psychiatric nurses acting within autonomous scope of practice communicate and collaborate with the client (or their substitute decision-maker) about nursing diagnoses, decisions, actions, and outcomes to support the client to be an active participant in making informed decisions about the care to meet the client’s needs.
10.	Registered psychiatric nurses acting within autonomous scope of practice communicate and collaborate with the health care team about nursing diagnoses, decisions, actions, and outcomes.
11.	Registered psychiatric nurses acting within autonomous scope of practice communicate and collaborate with the health care professional who gave the order (or their delegate), the client, and other members of the health care team when changing or cancelling a client-specific order for activities that are within the nurse’s autonomous scope of practice and individual competence.
12.	Registered psychiatric nurses acting within autonomous scope of practice consult with, or refer clients to, other health care professionals when:
	a.	The needs of the client exceed their scope of practice or individual competence,
	b.	Required by organizational/employer policies or processes, or
	c.	Client care would benefit from the expertise of other health care professionals.

BCCNM limits and conditions for registered psychiatric nurse

Acting within autonomous scope of practice

Activity		BCCNM Limits and Conditions for Registered Psychiatric Nurse: Acting within Autonomous Scope of Practice
1.	Use of restraint and seclusion	a. When using restraint or seclusion^[5]interventions, registered psychiatric nurses must follow applicable legislation^[6] specific to their practice setting. b. When using mechanical restraint^[7] or seclusion interventions with clients certified under the Mental Health Act, registered psychiatric nurses must act with a client-specific order from an authorized health professional, except in an emergency situation.
2.	Pronounce death	a. Registered psychiatric nurses must follow a decision support tool approved by their employer when pronouncing unexpected death.
3.	Do not pronounce death related to medical assistance in dying (MAiD)	a. Registered psychiatric nurses *must not* pronounce death related to medical assistance in dying (MAiD).
4.	Financial incapability assessment	a. Registered psychiatric nurses must successfully complete the educational program titled A Guide to the Certificate of Incapability Process under the Adult Guardianship Act, provided by the Ministry of Health (Certificate of Incapability process for healthcare professionals \| Public Guardian and Trustee of British Columbia) b. Registered psychiatric nurses must follow the guidelines contained in the document A Guide to the Certificate of Incapability Process under the Adult Guardianship Act" prepared by the Ministry of Health and the Public Guardian and Trustee of British Columbia (Certificate of Incapability process for healthcare professionals \| Public Guardian and Trustee of British Columbia)
5.	Incapability assessment for care facility admission	a. Registered psychiatric nurses must successfully complete the Ministry of Health “Consent to Care Facility Admission in British Columbia: A Course for Managers and Assessors" (LearningHub: Consent to Care Facility Admission in British Columbia: A Course for Managers and Assessors) b. Registered psychiatric nurses must follow the Ministry of Health guidelines, “Practice Guidelines for Seeking Consent to Care Facility Admission" (Province of British Columbia: Practice Guidelines for Seeking Consent to Care Facility Admission)
6.	Perform wound care	a. Registered psychiatric nurses must successfully complete additional education before carrying out: i. Conservative sharp wound debridement ii. Negative pressure wound therapy iii. Biological debridement therapy iv. Compression therapy b. Registered psychiatric nurses must follow an employer approved decision support tool in carrying out: i. Conservative sharp wound debridement ii. Negative pressure wound therapy iii. Biological debridement therapy iv. Compression therapy
7.	Perform venipuncture	a. Registered psychiatric nurses must successfully complete additional education to perform venipuncture. b. Registered psychiatric nurses are limited to using short peripheral venous access devices to take blood.
8.	Perform venipuncture: Do not take blood for donation	a. Registered psychiatric nurses *must not* take blood for the purpose of donation.
9.	Establish intravenous (IV) access	a. Registered psychiatric nurses must successfully complete additional education to perform venipuncture or establish intravenous access. b. Registered psychiatric nurses are limited to using short peripheral venous devices to establish intravenous access.
10.	Administer nutrition by enteral instillation	a. Registered psychiatric nurses are limited to administering enteral feeds to clients with stable and predictable physiological health and an established diet.
11.	Administer purified protein derivative by injection for tuberculosis (TB) screening	a. Registered psychiatric nurses who administer purified protein derivative must possess the competencies outlined in Competencies for Tuberculosis Screening Competencies established by the British Columbia Centre for Disease Control (BCCDC) (TB_screening_competencies.pdf) or equivalent approved by their employer. b. Registered psychiatric nurses who administer purified protein derivative must follow the BCCDC Decision Support Tool: Non-Certified Practice - Tuberculosis Screening (BCCDC Clinical Prevention Services Decision Support Tool: Non-Certified Practice - Tuberculosis Screening) or equivalent approved by their employer.
12.	Administer a solution by irrigation: irrigate bladder administer a solution by enteral instillation	a. Registered psychiatric nurses must act with a client-specific order from an authorized health professional to irrigate a bladder. b. Registered psychiatric nurses are limited to administering a solution through enteral instillation to clients with stable and predictable physiological health.
13.	Put an instrument or device beyond the point in the nasal passages where they normally narrow: nasopharyngeal suctioning nasogastric tubes	a. Registered psychiatric nurses must follow a decision support tool approved by their employer when carrying out nasopharyngeal suctioning. b. Registered psychiatric nurses are limited to re-inserting previously established nasogastric tubes (e.g., replacing a blocked tube) within their autonomous scope of practice. Initial insertion of a nasogastric tube requires a client-specific order from an authorized health professional.
14.	Put an instrument or device beyond the pharynx: Do not perform endotracheal Intubation	a. Registered psychiatric nurses *must not* carry out endotracheal intubation.
15.	Put an instrument or a device beyond the opening of the urethra: insert or flush catheter	a. Registered psychiatric nurses must follow a decision support tool approved by their employer when inserting or flushing a catheter.
16.	Put an instrument or a device, or finger beyond the labia majora: pelvic exams cervical cancer screening	a. Registered psychiatric nurses who carry out pelvic exams or cervical cancer screening must i. successfully complete additional education and ii. possess the competencies (BCCDC: Competencies for Pelvic Examination) established by the Provincial Health Services Authority (PHSA) or equivalent approved by their employer. b. Registered psychiatric nurses who carry out pelvic exams or cervical cancer screening must follow the Pelvic Exam by Registered Nurses and Registered Psychiatric Nurses decision support tool established by PHSA (PHSA: Pelvic Exam by Registered Nurses and Registered Psychiatric Nurses) or an equivalent approved by their employer.
17.	Put an instrument or a device, hand or finger into an artificial opening into the body: suprapubic and gastrostomy tubes ostomy care tracheostomy care	a. Registered psychiatric nurses are limited to inserting suprapubic and gastrostomy tubes in clients with stable and predictable physiological health. b. Registered psychiatric nurses are limited to carrying out ostomy care for clients with stable and predictable physiological health. c. Registered psychiatric nurses are limited to carrying out tracheostomy care for clients with stable and predictable physiological health.
18.	Apply electricity: Do not use a manual defibrillator	a. Registered psychiatric nurses *must not* apply electricity using a manual defibrillator.
19.	Apply electricity: use an automated external defibrillator (AED)	a. Registered psychiatric nurses must successfully complete, and maintain currency in, a course on cardiopulmonary resuscitation and automated external defibrillator (AED) use for health care professionals in order to apply electricity using an AED.
20.	Order X-rays for tuberculosis screening except computerized axial tomography (CAT scan)	a. Registered psychiatric nurses who issue an instruction or authorization for a chest X-ray for the purpose of tuberculosis screening must possess the competencies outlined in Tuberculosis Screening Competencies established by the British Columbia Centre for Disease Control (BCCDC) (BCCDC: TB Screening Competencies) or equivalent approved by their employer. b. Registered psychiatric nurses who issue an instruction or authorization for a chest X-ray for the purpose of tuberculosis screening must follow the BCCDC Decision Support Tool: Non-Certified Practice - Tuberculosis Screening (BCCDC Clinical Prevention Services Decision Support Tool: Non-Certified Practice - Tuberculosis Screening) or equivalent approved by their employer.
21.	Prescribe medications	a. Registered psychiatric nurses only prescribe medications[4]when they: i. Have a certified practice designation; AND ii. Meet the requirements for certified practice registered psychiatric nurses to prescribe for the treatment of opioid use disorder. This restriction against a non-certified practice RPN prescribing does not prevent them from issuing a client-specific ‎order to be acted on by another nurse to compound, dispense or administer a medication for a ‎specific client that is within the ordering RPN's autonomous scope of practice.
22.	Treat anaphylaxis	a. Registered psychiatric nurses are limited to administering epinephrine to treat anaphylaxis. b. Registered psychiatric nurses who administer epinephrine to treat anaphylaxis must follow decision support tools (BCCDC: Communicable Disease Control Manual Chapter 2: Immunization Part 3 - Management of Anaphylaxis in a Non-Hospital Setting) in the Communicable Disease Immunization Program Section V - Management of Anaphylaxis in a Non-hospital Setting² established by British Columbia Centre for Disease Control (BCCDC) or equivalent approved by their employer. c. Registered psychiatric nurses who administer epinephrine must successfully complete additional education.
23.	Administer medications: Do not administer, compound, dispense Schedule I drugs for opiate overdose (*Drug Schedules Regulation*)	a. Registered psychiatric nurses *must not* administer, compound or dispense a Schedule I drug to treat a suspected opiate overdose
24.	Treat respiratory distress (clients with known asthma)	a. Registered psychiatric nurses are limited to administering salbutamol or ipratropium bromide to treat respiratory distress in known asthmatics. b. Registered psychiatric nurses who administer salbutamol or ipratropium bromide to treat respiratory distress in a known asthmatic must follow a decision support tool approved by their employer. c. Registered psychiatric nurses who administer salbutamol or ipratropium bromide must successfully complete additional education.
25.	Treat hypoglycemia	a. Registered psychiatric nurses are limited to administering D50W to treat hypoglycemia. b. Registered psychiatric nurses who administer D50W to treat hypoglycemia must follow a decision support tool approved by their employer. c. Registered psychiatric nurses who administer D50W must successfully complete additional education.
26.	Compound, dispense or administer antivirals for influenza-like illness	a. Registered psychiatric nurses who compound, dispense or administer antiviral medication to treat symptoms of influenza-like illness must successfully complete additional education. b. Registered psychiatric nurses who compound, dispense or administer antiviral medication to treat symptoms of influenza-like illness must follow, the decision support tool established by the Provincial Government: RN and RPN Decision Support Tool (Clinical Practice Guidelines) for Identification and Early Treatment of Influenza-Like Illness (ILI) Symptoms during an Influenza Pandemic in the Absence of a Medical Practitioner or Nurse Practitioner. (BC Government: RN and RPN Decision Support Tool (Clinical Practice Guidelines) for Identification and Early Treatment of Influenza-Like Illness (ILI) Symptoms during an Influenza Pandemic in the Absence of a Medical Practitioner or Nurse Practitioner or equivalent approved by their employer.
27.	Do not compound, dispense or administer antiviral medication to treat symptoms of influenza-like illness for children under 4 years	a. Registered psychiatric nurses *must not* compound, dispense or administer antiviral medication to treat symptoms of influenza-like illness for children under the age of 4.
28.	Compound, dispense or administer Immunoprophylactic agents and post-exposure chemoprophylactic agents	a. Registered psychiatric nurses who, within their autonomous scope of practice, compound, dispense or administer immunoprophylactic or chemoprophylactic agents identified by the BC Centre for Disease Control (BCCDC) must: i. possess the competencies established by BCCDC (BCCDC: Immunization Competencies for BC Health Professionals). ii. follow decision support tools established by BCCDC. b. Registered psychiatric nurses who compound, dispense or administer post-exposure chemoprophylactic agents for sexual assault purposes must: i. possess the BC Women's Sexual Assault Service (BCWSAS) Competencies for (registered nurse) sexual assault nurse examiners (Sexual Assault Service Resources for Health Professionals), and ii. follow Decision Support Tools (DST) for Sexual Assault Nurse Examiners (SANES) for (registered nurse) sexual assault nurse examiners (Sexual Assault Service Resources for Health Professionals) established by BC Women's Sexual Assault Service (BCWSAS).
29.	Do not compound, dispense or administer immunoprophylactic or post-exposure chemoprophylactic agents for: preventing disease in travellers children under 4 years	a. Registered psychiatric nurses *must not* compound, dispense or administer immunoprophylactic or post-exposure chemoprophylactic agents for the purpose of preventing disease in travellers (also known as travel health). b. Registered psychiatric nurses *must not*, within their autonomous scope of practice, compound, dispense or administer immunoprophylactic agents or post-exposure chemoprophylactic agents for children under the age of 4 years old.
30.	Do not compound or administer experimental vaccines for research purposes	a. Registered psychiatric nurses *must not* compound or administer experimental vaccines for research purposes.
31.	Compound, dispense, or administer Schedule II drugs (*Drug Schedules Regulation*)	a. Registered psychiatric nurses require a client-specific order from an authorized health professional to compound, dispense or administer Schedule II medications to treat a disease or disorder. For example, nurses would not administer insulin without knowing that a physician had diagnosed diabetes and ordered insulin therapy. b. Registered psychiatric nurses may only compound, dispense or administer Schedule II medications to treat a condition following an assessment and nursing diagnosis. Vaccines do not require the identification of a condition. c. Registered psychiatric nurses who administer Schedule II drugs intravenously via a peripheral venous access device must either: i. follow an employer approved decision support tool or ii. act with a client-specific order from an authorized health professional. d. Registered psychiatric nurses who administer medication via central venous access devices must: i. act with a client-specific order from an authorized health professional, and ii. successfully complete additional education to administer medication via central venous access devices.
32.	Compound, dispense, or administer Schedule II drugs: Do not perform insulin dose adjustment Do not administer medication by these routes (*Drug Schedules Regulation*)	a. Registered psychiatric nurses *must not* carry out Insulin dose adjustment. b. Registered psychiatric nurses *must not* administer medication via intrathecal, epidural, intraosseous or perineural routes because it is not within RPN scope of practice
33.	Medical aesthetics^[5]	a. Registered psychiatric nurses successfully complete additional education before providing medical aesthetic procedures. b. Registered psychiatric nurses administering injectable drugs or substances or implantable devices for medical aesthetic purposes only do so: i. with a client-specific order from an authorized health professional, and ii. when the ordering health professional, or another health professional who has assumed responsibility for the care of the client, is present within the facility when the procedure is being performed and immediately available for consultation. c. Registered psychiatric nurses *do not* prescribe dermal fillers.

Glossary

Additional education: Additional education is structured education (e.g., workshop, course, program of study) designed for the nurse to attain the competencies required to carry out a specific activity. Additional education:

Builds on the entry-level competencies,
Identifies the competencies expected of learners on completion of the education,
Includes both theory and application to practice, and
Includes an objective evaluation of learners' competencies on completion of the education.

Advanced activities: Activities that are within a nurse's scope of practice but require additional education, training, and/or clinical experience that build on the foundational knowledge, skills, and judgement attained during entry-level nursing education.

Competence: The integration and application of current knowledge, skills, attitudes, and judgment required to perform safely, ethically, and appropriately within an individual's practice.

Competencies: The knowledge, skills, attitudes, and judgment required to provide safe, competent, and ethical care within an individual's practice or in a designated role or setting.

Decision support tools (DSTs): Evidence-based documents used by nurses to support clinical judgment and decision-making by guiding the assessment, diagnosis and treatment of client-specific clinical problems. DSTs come in various forms and are created by organizations or specialists in a specific area of health care.

Footnotes

[1] Nursing diagnosis: a clinical judgment of an individual's mental or physical condition to determine whether the condition can be ameliorated or resolved by appropriate interventions of the nurse to achieve outcomes for which the nurse is accountable: Nurses (Registered Psychiatric)Regulation.

[2] Certified practice registered psychiatric nurses may also make a diagnosis of a disease, disorder or condition that is within the autonomous scope of the nurse's certified practice designation and the nurse's individual competence.

[3] Based on their assessment of the client, registered psychiatric nurses make a clinical judgement (a nursing diagnosis) of a condition as the cause of the client’s signs and symptoms.

[4] Nursing diagnosis: a clinical judgment of an individual's mental or physical condition to determine whether the condition can be ameliorated or resolved by appropriate interventions of the nurse to achieve outcomes for which the nurse is accountable: Nurses (Registered Psychiatric) Regulation.

[5] Seclusion is a physical intervention that involves containing a client in a room from which free exit is denied (Government of BC, Ministry of Health, 2012, Secure rooms and seclusion standards and guidelines: A literature and evidence review).

[6] If restraint and seclusion is not done with legislative authority, the act may be an assault. Some examples of provincial and federal legislation which may be applicable to the use of restraint and seclusion are the Residential Care Regulation Community Care and Assisted Living Act, Mental Health Act, Corrections Act, the Criminal Code of Canada and Corrections and Conditional Release Act.

[7] Mechanical restraint involves the use of devices to partially or totally restrict the client’s movements.

[8] In these standards, the term “prescribing" is used to describe the issuance of a prescription for a medication to be dispensed by a pharmacist or pharmacy.

[9] “Medical aesthetics" refers to elective non-surgical outpatient clinical procedures that include the performance of a restricted activity (activities listed in sections 6 and 7 of the Nurses (Registered Psychiatric) Regulation) and are primarily intended to alter or restore a person's appearance.

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Acting Within Autonomous Scope of Practice

Int​rod​​​u​ction

​​Sta​ndards