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Client care

Preventing nurse-to-client infections
I think I have the flu. If I call in sick, the unit will be short-staffed. Can I work?

If you have flu-like symptoms such as fever, chills and achiness, stay home. It may be difficult for you to work effectively and you may be contagious. Although it’s difficult knowing your absence might impact your colleagues’ work, you have a duty to protect your clients from the risk of infection. Staying home when ill is one way to do this. Washing your hands frequently and keeping your immunizations up to date are other ways to prevent infection and provide safe care to your clients.

The Communicable Diseases: Preventing Nurse-to-Client Transmission Practice Standard provides more information about your responsibilities to provide safe care to clients.

For personal reasons, I don’t want to/or can’t have a flu shot. Will I lose my licence if I refuse?

While you’re not required to have a flu shot to be registered with CRNBC, you are responsible for protecting your clients from the risk of infection. Nurses have a professional, ethical and legal duty to provide clients with safe care.

The Communicable Diseases: Preventing Nurse-to-Client Transmission Practice Standard provides more information about your responsibilities to provide safe care to clients.

The BC Ministry of Health has a policy for immunizations and health care staff. Be sure to check your employer’s policies for staff immunizations and influenza control.

Medications
I'm considering taking a job at a medical aesthetic clinic where I would administer Botox Cosmetic and dermal fillers. Is this within RN scope of practice?

Yes, administering Botox and dermal fillers are within RN scope of practice. Botox is a Schedule 1 medication. Dermal fillers are either Schedule 2 medications or substances. In all cases, you'll need a client-specific order from a physician or dentist and to meet the Standards for acting with client-specific orders.

CRNBC has recently clarified that RNs always require an order before compounding or administering dermal fillers , as these procedures come with potential client risks, there are many things to consider before carrying out these activities. We recommend you review the following resources:

The College of Physicians and Surgeons of British Columbia and the College of Dental Surgeons of British Columbia have information relevant to nurses administering Botox Cosmetic and dermal fillers. Please contact practice@crnbc.ca if you have any questions.

In our clinic, we use sclerosing agents to treat varicose veins. Do I need an order to administer these?

Yes, you need an order. Although many sclerosing agents are Schedule II medications, you would administer these agents to treat a disorder, such as varicose veins, only after a physician has assessed the client, diagnosed the disorder and ordered the sclerotherapy.

RNs can administer Schedule II medications without an order to treat a condition they’ve diagnosed, but we’re not aware of any conditions that RNs could treat autonomously by administering a sclerosing agent.

See the Scope of Practice for Registered Nurses for more information and guidance.

Can I recommend herbal supplements to my clients?

When recommending or participating in complementary and alternative health care (CAHC) practices, your primary duty continues to be providing ethical and competent care. If you are recommending any CAHC practice, you must:

  • provide evidenced-based information.
  • ensure it does not pose a greater risk to the client than conventional treatment
  • ensure it does not interfere with other current treatments

Visit the complementary & alternative health care page for more information.

In our facility, we provide residents with medications when they leave on day pass. What’s our responsibility when we do this?

If a pharmacist has already dispensed your client's medications to your unit or agency, you’re responsible for taking steps to ensure proper use. This includes:

  • making sure the medication is labelled and packaged appropriately for the client,
  • providing your client with information about the medication, including its purpose, possible side effects, and when and how to take it
  • documenting the dispensed medications on the client’s record

The Dispensing Medications Practice Standard provides clear direction for labelling, packaging, client education and documentation. Agency policies should reflect these requirements.

I work in a rural community hospital. Sometimes our local physician phones in a prescription for someone who is not a client. We don’t have a pharmacist on site, so we are asked to fill it when the person comes to the ER. Should we do this?

Unless the person is a client under your care, you should not dispense medications to them. The Dispensing Medications Practice Standard sets clear requirements for nurses when dispensing.

Agency policy and practice should support appropriate dispensing by nurses. If you are not able to meet the expectations set out in the practice standard, document this issue and discuss it with your manager.

What is the difference between preparing and pre-pouring medications? Can I pre-pour medications?

Preparing medications is part of the process of medication administration. Preparation includes selecting, calculating, crushing, breaking, mixing, labelling, drawing up, popping out, etc. You should prepare medications as close as possible to the time you administer them.

Pre-pouring medications is preparing medications in advance and storing them until you or others need them. Examples of this practice include:

  • Drawing up and labelling an IV medication for another nurse to administer later
  • Removing client medications from a blister pack, placing them in labelled medication cups, stacking the cups in the medication room, and administering them throughout your shift
  • Preparing a PRN medication in a syringe, labelling it and administering it throughout your shift and/or leaving it for other nurses to administer later

You should not pre-pour medications as it can blur the accountability for making sure the seven rights are met and/or increases the possibility of errors.

If you can’t administer medications immediately after preparing them, make sure they are securely stored. Follow your agency policies and use your professional judgment when deciding how far in advance to prepare your medications.

There are some situations where you may share the responsibility for preparing and administering medications. Examples include:

  • In a life threatening situation, when the client’s need for medications is urgent, you draw up and label medications and another nurse gives them
  • You start an IV infusion that other nurses will be responsible for maintaining

You’ll find more information and guidance in the Medication Administration practice standard.

Can I carry out orders taken verbally and recorded by a pharmacist?

Yes, pharmacists can accept verbal orders from authorized health professionals and dispense medications accordingly. You may use the dispensing label in place of the health professional’s order, provided the medication is in the original pharmacy container and your agency permits it.

Can an RN dispense narcotics?

Yes, RNs can dispense medications, including narcotics, to clients under their care. RNs must meet the requirements set out in the Dispensing Medications Practice Standard and follow agency policy.

Documentation
How much charting am I required to do?

Your documentation should provide a clear picture of your client's status, your actions and client's outcomes, for example:

  • your assessment of the client's health status, nursing diagnoses and plan of care
  • interventions carried out, client's response and any changes to the plan of care
  • information and concerns reported to another health care provider and the provider's response
  • any advocacy carried out on behalf of your client

Your client’s condition and care needs are factors in determining how much and what documentation is required. Acutely ill or high risk clients or those with complex health problems will require more comprehensive, in-depth and frequent documentation.

The requirements for documentation come from legislation, case law, Standards of Practice and agency policies. Documenting is a way to show you have applied nursing knowledge, skills and judgement and met the legal standard of care. Document according to agency policy — these policies should reflect legislative and other requirements.

The Documentation practice standard provides information and direction for your documentation. The Canadian Nurses Protective Society  also has helpful resources.

Sometimes I am unable to complete all my client assessments according to our protocols. What should I chart in the client’s record?

Chart the care you were able to provide, including any assessments, nursing interventions and changes to the client’s plan of care. Communicate to your manager through established processes - that you were unable to follow specific protocols and outline the circumstances that prevented you from doing so. Complete a patient safety learning event report or equivalent if directed by your agency policy.

Refer to the Documentation practice standard for more information and guidance.

I’m an instructor in a nursing program. Do I need to co-sign my students’ documentation?

CRNBC does not require you to co-sign students’ documentation. Nursing students are responsible and accountable for documenting the care they personally provide to clients.

In some situations, it may be necessary for an RN (such as a preceptor or faculty) to document their own assessment, interventions and evaluations. For example, if a client developed an acute or complex problem, the RN may need to document her/his assessment and response to the problem, in addition to the student’s documentation. Use your professional judgment to determine if additional documentation is necessary.

Employers may set additional requirements related to documentation and working with students. Ask a clinical educator or manager for your unit whether there is such a policy. Regulatory Supervision of Nursing Student Activities provides direction additional for nurses working with students.

Thank you to the College of Registered Nurses of Manitoba for permission to adapt their content.

When I consult with other health care providers (such as other nurses, social workers, dietitians etc.), should I include their name in the progress notes of a patient’s chart?

Generally, if you consult with another health care provider (HCP) and receive direction and/or orders for your client’s care, you should document this. While other HCPs are responsible for documenting any orders or care they provide to a client, your documentation should accurately reflect the care you provide to a client, including when you’ve consulted with another health care provider, including their name and title. When documenting, include:

  • date, time and method of contact (e.g. phone call)
  • HCP’s name and title (e.g. Matt Smith, NP or Grace Lee, Midwife)
  • information you provided to the HCP
  • HCP’s response                          
  • any resulting orders/interventions that you carry out
  • agreed upon plan of action
  • anticipated outcomes

For example, if you seek clarification from a physiotherapist about mobilizing a client, record the reason for seeking clarification, name and title of the physiotherapist providing the clarification, action you took as the RN, and expected outcome. Update the plan of care as appropriate.

Professional judgement (and employer policy) is required to determine when it’s appropriate to document this. For example, you’ll need to distinguish between running an idea past someone to see what they think versus asking for direction for a client’s care from someone because they have particular expertise.

The Documentation practice standard provides more direction and information for your documentation.

Thank you to the College of Registered Nurses of Nova Scotia for permission to adapt their content.

Can we accept orders from physicians or nurse practitioner by text messaging or email?

CRNBC Standards (Scope of Practice, Medication Administration, and Documentation) don’t specifically address texting or email. Patient safety and best practices should be considered before engaging in this practice. Employer systems should be secure so that client information sent using technology cannot be changed in transit, is kept confidential and can be validated.

Review and follow relevant health authority/employer policy when using electronic devices to communicate client information. You’ll want to make sure:

  • client privacy and confidentiality (security) is protected
  • the client record contains timely and complete documentation of the information

Scope of practice
What is the difference between pronouncement and certification of death? Can RNs or NPs do either?

Pronouncement of death is the opinion or determination that, based on a physical assessment, life has ceased. Although there are presently no laws in B.C. governing who can pronounce death, your employer may have policies and procedures related to this.

Certification of death refers to the completion of the death certificate identifying the cause of death. Currently, only physicians, nurse practitioners and coroners can complete and sign death certificates. Registered nurses cannot.

You can find more information on completing death certificates in the BC Government’s Handbook for Physicians, Nurse Practitioners and Coroners.

Do I need to be CRNBC-certified to carry out pelvic exams and Pap smears?

No, carrying out pelvic exams and Pap smears is within the scope for practice for all RNs.

If you’re carrying out these activities, you’ll need to meet the Standards for acting within autonomous scope of practice. This includes making sure you have the necessary competencies and follow the DSTs established by the Provincial Health Services Authority (PHSA).

I work in an STI clinic where I do assessments and physical exams, collect specimens, and provide counselling and education. Do I need to be CRNBC-certified?

Not necessarily. These activities are within the scope of practice for all RNs. However, if your role includes autonomously diagnosing and/or treating specific diseases and disorders with Schedule 1 (prescription level) medications, you’ll need to be CRNBC-certified.

I work in the emergency department of a rural hospital. Carrying out “emergency activities” is part of my job. My employer says the emergency exemption covers these situations.

The emergency exemption generally does not apply in this situation.

The Health Professions Act's emergency exemption is meant to deal with situations that:

  • arise unexpectedly;
  • involve imminent risk of death or serious harm; and
  • require urgent action.

The emergency exemption does not cover activities that are an expectation of a nurse’s role, including activities that would be expected to arise from time to time in the ordinary course of your employment. Neither you nor your employer should rely on the emergency exemption to allow you to carry out activities considered an expectation of practice in your setting.

You’ll find more information and guidance about your legal and professional obligations to clients and scope of practice in the Scope of Practice for RNs: Standards, Limits and Conditions and the Duty to Provide Care practice standard.

Is incision and drainage of an abscess part of CRNBC-certified practice?

No, incision and drainage is outside the scope of practice of CRNBC-certified nurses. Nurse practitioners are the only nurses who may perform this intervention. Check Certified Practice and Scope of Practice for NPs for more information and guidance on scope.

Some of my clients do not have a primary care provider. When the care they need is outside my scope and I don’t have an NP or physician to consult with or refer them to, what can I do?

These situations are usually beyond an individual nurse’s control and often require a systems level approach for resolution.

In these types of situations, you could:

  • Consult with your colleagues and/or others to identify possible options such as setting up a process for contacting and getting orders from a community physician or NP, at a walk-in/telemedicine clinic or in a nearby emergency room
  • Discuss the situation with your manager/supervisor, identifying the concerns and possible courses of actions
  • Follow up the discussion with appropriate documentation
  • Advocate for safe and appropriate client care by helping to develop policies and practices to address these situations
Resolving Professional Practice Problems can help guide you through this problem-solving process. The Professional Standards and Duty to Provide Care practice standard may provide additional information and direction.

Telehealth
I work in a department where patients call and ask for advice. Can I give advice over the phone?

When you give advice over the phone you are accountable for the care you provide. By answering the phone you initiate a nurse-client relationship and a duty to provide care. When offering telephone advice you must have the competence to assess the health needs of callers and provide appropriate advice, including referring to other services. You must also follow agency policy.

Your ability to assess a situation over the phone may be influenced by:

  • lack of opportunity to observe the client
  • communication and/or language barriers
  • the caller’s ability  to accurately describe the situation
  • the caller’s emotional state
  • your skill in asking appropriate questions

Recognize when providing advice over the phone is not appropriate.

When documenting the call, include:
  • date and time
  • caller’s name and  number
  • reason for call 
  • any assessment data and conclusions drawn
  • any advice given, including when to seek further care
  • your signature and title

Your agency policies should outline the required competencies, the type of advice you may give and documentation processes. They should also include guidelines for informing clients about when and how to seek further care.

Your agency policies should outline the required competencies, the type of advice you may give and documentation processes. They should also include guidelines for informing clients about when and how to seek further care. The Telehealth, Boundaries in the Nurse-Client Relationship, Consent and Documentation practice standards will provide further information and guidance about your responsibilities when providing advice over the phone.

 Need help?

For further information on the Standards of Practice or professional practice matters, contact us:

  • Telephone 604.736.7331 ext. 332
  • Toll-free in Canada 1.800.565.6505
  • Email practice@crnbc.ca
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