Int​rodu​ction

The Registered Nurses: Acting under Client-specific Orders practice standards, limits, and conditions set the expectations that registered nurses^[1] must meet when they are performing activities that they are competent and allowed to perform under client-specific orders.

Registered nurses' scope of practice under the Nurses and Midwives Regulation includes providing health services for the purpose of promoting, maintaining and restoring clients' physical and mental health.

For the restricted activities listed in section 21 and 22 of the Nurses and Midwives Regulation, a registered nurse may perform the activity only if acting under a client-specific order given by a physician, nurse practitioner, dentist, midwife, naturopathic physician, podiatrist, pharmacist, certified registered nurse, or certified registered psychiatric nurse.^[2]

Depending on organizational or employer policies and processes, certain health professionals not named in the Nurses and Midwives Regulation may still give client‑specific orders for activities already within the nurse's autonomous scope of practice. These orders are not legally required since the activity is already authorized within the nurse's scope, but the specialized expertise and competence of the other health professionals can help determine the best care for the client and strengthen team‑based assessment and care planning.

Standards

1.        Registered nurses require a client-specific order before performing any activity that is not within the registered nurse's autonomous scope of practice.

2.      Registered nurses acting under a client-specific order ensure the ordered activity is:

​​a. Either one of the restricted activities identified in section 21 or 22 of the Nurses and Midwives Regulation that registered nurses may perform when acting under an order or an activity within the registered nurse's autonomous scope of practice,
b. Consistent with BCCNM's ethics standards and practice standards, including any applicable limits and conditions on performing the activity,
c. Consistent with organizational/employer policies, processes, and restrictions, and
d. Within their individual competence.

3.      Registered nurses acting under a client-specific order ensure that they have the competence to:

​​a. Perform the activity safely and ethically,
b. Identify potential risks of the activity to the client and know how to minimize those risks, and

c. Recognize and ​manage the intended outcomes of the activity.

4.      Before performing an activity under a client-specific order, registered nurses consider applicable employer/organizational policies, processes, and resources, restrictions, 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 nurses perform advanced activities with a client-specific order 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 nurses acting under a client-specific order ensure that the order:

​​a. Is client-specific,
b. Is clear and complete,
c. Is documented, legible, dated and signed with a written/electronic signature, and

d. C​ontains enough information for the nurse to carry it out safely.

7.       Registered nurses accept a verbal or telephone client-specific order only when there is no reasonable^[3] alternative, according to organizational/employer policies and processes, and when doing so is in the best interest of the client. Nurses repeat the client-specific order back to the ordering health professional to confirm its accuracy and promptly document the order.

8.      Registered nurses conduct assessments to ensure that the client's condition continues to warrant the activity before acting under a client-specific order.

9.      Registered nurses may not change or cancel a client-specific order when the activity is outside of the registered nurse's autonomous scope of practice or the registered nurse's individual competence.

10.    Registered nurses communicate and collaborate with the health professional (or their delegate) who gave the client-specific order, follow organizational/employer policies and processes, take action as needed, and document in the client record, when:

a. The order​ed activity may no longer be appropriate because the client's condition, needs or wishes have changed (e.g., to 'hold' the order),

b. They are not able to carry out a client-specific order,

c. The client-specific order does not appear to consider a client's individual characteristics, values/beliefs, and preferences,

d. The client-specific order does not appear to reflect current evidence or be in the best interest of the client,

e. They change or cancel a client-specific order for activities that are within their autonomous scope of practice, or

f. The safeguards and resources are not available to manage the outcomes of performing the activity, including reasonably foreseeable unintended outcomes.

11.      Registered nurses follow the standards for Acting within Autonomous Scope of Practice when they change or cancel a client-specific order that is within their autonomous scope of practice and individual competence.

12.     Registered nurses are responsible and accountable for any changes or cancellations they make to a client-specific order that is within their autonomous scope of practice and individual competence.

13.     Registered nurses obtain a client-specific order to perform an activity or provide care or a service that is within their autonomous scope of practice when:

​a. It is required by organizational/employer policies, processes, or restrictions,

b. There are insufficient organizational/employer supports, processes and resources in place (such as decision support tools or clinical practice documents) to enable the nurse to meet BCCNM standards, limits, or conditions related to the activity, care or service, or

c. The registered nurse is competent to perform the activity or provide the care or service but does not have the individual competence to make a nursing diagnosis or carry out an assessment to determine whether the client would benefit from the activity, care, or service.

14.     Registered nurses only act with a client-specific order from a health professional who is not identified in the Nurses and Midwives Regulation as allowed to give a client-specific order to authorize a registered nurse to perform a restricted activity, when:

a. ​The activity is within the registered nurse's autonomous scope of practice,

b. The registered nurse is able to meet BCCNM standards, limits, or conditions related to the activity,

c. The activity is within the registered nurse's individual competence, and

d. Organizational/employer policies, and processes exist that:

​i.  clarify the accountability and responsibility of the nurse and the non-listed health professional, and

ii. outline the requirements for the non-listed health professional to complete an assessment and to ensure that the ordered activity is in the best interest of the client.

BCCNM limits and conditions for registered nurse

Actin​​g with client-specifi​c orders

Activity	BCCNM Limits Conditions for Registered Nurses: Acting under Client-specific Orders
1.       Cardiac stress testing	a. Registered nurses may only carry out cardiac stress testing under a physician's direction and only following successful completion of additional education.
2.      Venipuncture Insert a central venous catheter (CVC)[4]	a. Registered nurses act under a client-specific order to insert a central venous catheter.
3.      Procedures on tissue Surgical suturing or harvesting veins	a. Registered nurses must successfully complete an RN First Assist Program before doing surgical suturing or harvesting veins under a physician's client-specific order.
4.      Apply a cast for a fracture of a bone	a. Registered nurses who cast a fracture of a bone: b. Act under a client-specific order only from a physician or nurse practitioner c. Must successfully complete additional education.
5.      Insertion beyond the pharynx Do not perform endotracheal intubation	a. Registered nurses do not carry out endotracheal intubation.
6.      Insertion beyond the labia majora Pelvic exams Cervical cancer screening Fit a pessary Apply fetal scalp electrodes	a. Registered nurses who carry out pelvic exams or cervical cancer screening must possess the competencies established by Provincial Health Services Authority (PHSA) and follow decision support tool established by PHSA (PHSA: Pelvic Exam by Registered Nurses and Registered Psychiatric Nurses Decision Support Tool & Competencies (Appendix C) ). b. Registered nurses act under a client-specific order to fit a pessary. c. Registered nurses act under a client-specific order to apply fetal scalp electrodes.
7. Hazardous energy  Electrocautery	a. Registered nurses must successfully complete an RN First Assist Program before doing electrocautery under a physician's client-specific order.
8. Administer a Schedule I, IA or II drug Administer a substance by inhalation Do not induce general anesthesia	a. Registered nurses do not induce general anesthesia or give the first dose of anesthetic agents administered through a catheter.
9. Administer experimental medications	a. Registered nurses may, under a client-specific order, administer experimental medications not yet listed in any drug schedule as part of a formal research program.
10.    Compound, dispense, administer a Schedule II drug Treat a disease or disorder (Drug Schedules Regulation)	a. Registered nurses act under a client-specific order before compounding, dispensing or administering Schedule II medications to treat a disease or disorder.
11.      Therapeutic diets Compound, administer, or dispense a therapeutic diet by enteral instillation	a. Within autonomous scope of practice, registered nurses compound, administer, or dispense a therapeutic diet administered through enteral instillation only to clients who are stable and have an established diet. b. Registered nurses act under a client-specific order for all other clients
12.    Medical aesthetics[5]	a.       Registered nurses successfully complete additional education before providing medical aesthetic procedures. b.      Registered nurses administering injectable drugs or substances or implantable devices for medical aesthetic purposes only do so: i. Under a client-specific order, 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 nurses do not prescribe dermal fillers.

​​Glossary​

Activities: Refers to restricted activities or any other activity that is related to the care of clients that requires the professional knowledge, skills, ability and judgment of a nurse.

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, ability, a​nd judgement attained during entry-level nursing education.

Client: Person receiving​ health services.

​​Client-specific order: An instruction or authorization given by a regulated health professional to provide care for a specific client, whether or not the care or service includes a restricted activity or a non-restricted activity.

Competence: The integration and application of current knowledge, skills, ability, and judgment required to perform ethically, safely and in accordance with all applicable ethics standards and practice standards.

Competencies: The knowledge, skills, ability 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.

Nursing diagnosis: A clinical judgment made by a nurse of a client's mental or physical condition to determine whether the condition can be prevented, improved, ameliorated or resolved by the performance of activities or provision of other care or services that is within the nurse's scope of practice to provide without an assessment or diagnosis of the client by another regulated health professional.

Restricted Activity: An activity that is performed in the course of providing a health service and is prescribed by the regulations under the Health Professions and Occupations Act as a restricted activity. ​

​​Foot​​​notes​

[1] References to registered nurses include registered nurses, licensed graduate nurses and certified registered nurses.  

[2] Certified registered nurses do not require an order for a restricted activity listed in sections 21 and 23 of the Nurses and Midwives Regulation that is within the autonomous scope of the certified registered nurse's certification and their individual competence.

[3]  “Reasonable" refers to the common understanding that licensees of BCCNM would have as to what is appropriate in the situation.

[4] This may also be referred to as a central venous access devices (CVAD) or central venous device (CVD).

[5] “Medical aesthetics" refers to elective non-surgical clinical procedures that include the performance of a restricted activity and are primarily intended to alter or restore a person's appearance.