M-9, r. 23.1 - Regulation respecting specialized nurse practitioners

Updated to 7 February 2018

This document has official status.

not in force

chapter I-8, r. 15.1.1

Regulation respecting specialized nurse practitioners

Nurses Act

(chapter I-8, s. 3).

Medical Act

(chapter M-9, s. 19, 1st par., subpar. b).

CHAPTER I GENERAL

O.C. 84-2018, c. I.

1. The purpose of this Regulation is to determine, among the medical activities that may be performed by physicians, those that, pursuant to the terms and conditions set out in the Regulation, may be performed by the following persons:

(1)  a specialized nurse practitioner, that is, a nurse who holds a specialist’s certificate in any of the classes of specialization referred to in the Regulation respecting the classes of specialization of specialized nurse practitioner (chapter I-8, r. 8);

(2)  a specialized nurse practitioner student, that is, a nurse who holds a training card issued in accordance with the Regulation respecting the classes of specialization of specialized nurse practitioner;

(3)  a specialized nurse practitioner candidate, that is, a nurse who holds an attestation of practice issued in accordance with the Regulation respecting the classes of specialization of specialized nurse practitioner.

O.C. 84-2018, s. 1.

2. For the purposes of this Regulation,

(1)  “isolated region facility” means a primary care facility or a dispensary listed in Schedule I;

(2)  “chronic disease” means a disease that has been the subject of a diagnosis by a physician and of a medical treatment plan giving the expected results;

(3)  “common health problem” means a health problem that presents the following characteristics:

(a)  a relatively high incidence in the community;

(b)  clinical symptoms and signs usually affecting a single system;

(c)  an absence of deterioration in the general condition of the person;

(d)  usually a quick and favourable course.

(4)  “primary care” means health care that presents the following characteristics:

(a)  it is intended for persons, mainly living at home, having common health needs or problems;

(b)  it includes a series of common health services based on a simple infrastructure in diagnostic and therapeutic means;

(5)  “secondary care” means health care that presents the following characteristics:

(a)  it is intended for persons with a severe loss of functional or psychosocial autonomy and for persons with complex health problems that cannot be solved by primary care;

(b)  it includes assistance, support and lodging services and a series of mainly specialized health services based on a complex infrastructure in diagnostic and therapeutic means;

(6)  “tertiary care” means health care that presents the following characteristics:

(a)  it is intended for persons having health problems that are very complex or have a low prevalence;

(b)  it is highly specialized.

O.C. 84-2018, s. 2.

3. The term “infirmière” means infirmière or infirmier wherever it appears in the French text of this Regulation.

O.C. 84-2018, s. 3.

CHAPTER II ACTIVITIES THAT MAY BE PERFORMED

O.C. 84-2018, c. II.

4. A specialized nurse practitioner may perform the following medical activities in the nurse’s class of specialization, under the terms and conditions set out in Chapter III:

(1)  prescribe diagnostic examinations;

(2)  use diagnostic techniques that are invasive or entail risks of injury;

(3)  prescribe medications and other substances;

(4)  prescribe medical treatments;

(5)  use techniques or apply medical treatments that are invasive or entail risks of injury.

O.C. 84-2018, s. 4.

CHAPTER III TERMS AND CONDITIONS OF PRACTICE

O.C. 84-2018, c. III.

DIVISION I SPECIAL TERMS AND CONDITIONS

O.C. 84-2018, Div. I.

5. A nurse practitioner specialized in neonatology must perform the activities provided for in section 4 on a neonatal clientele in a hospital centre operated by an institution at which secondary or tertiary care is provided.

The nurse must hold a training certificate in neonatal resuscitation issued by the Canadian Paediatric Society.

O.C. 84-2018, s. 5.

6. A nurse practitioner specialized in pediatric care must perform the activities provided for in section 4 on a pediatric clientele that requires secondary or tertiary care.

O.C. 84-2018, s. 6.

7. A nurse practitioner specialized in adult care must perform the activities provided for in section 4 on an adult clientele that requires secondary or tertiary care.

O.C. 84-2018, s. 7.

8. A nurse practitioner specialized in mental health must perform the activities provided for in section 4 on a clientele of all ages in the field of mental health and human relations.

O.C. 84-2018, s. 8.

9. A nurse practitioner specialized in primary care must perform the activities provided for in section 4 on a clientele of all ages that requires primary care, including where the clientele is lodged in a residential and long-term care centre or a child and youth protection centre operated by an institution.

The clientele referred to in this section must meet one of the following conditions:

(1)  the clientele presents a common health problem;

(2)  the clientele has a chronic disease;

(3)  the clientele requires the monitoring of a normal or low-risk pregnancy;

(4)  the clientele requires palliative care and is lodged in a residential and long-term care centre operated by an institution.

A nurse practitioner specialized in primary care who performs the monitoring of a normal or low-risk pregnancy does so according to the terms established with the partner physician and described in the partnership agreement.

O.C. 84-2018, s. 9.

10. Despite the second paragraph of section 9, a nurse practitioner specialized in primary care may perform, on the conditions prescribed in the first paragraph of that section, the activities provided for in section 4 for the purpose of initiating treatment of the following chronic health problems:

(1)  diabetes;

(2)  hypertension;

(3)  hypercholesterolemia;

(4)  asthma;

(5)  chronic obstructive pulmonary disease;

(6)  hyperthyroidism.

After having initiated treatment of one of those problems, the nurse practitioner specialized in primary care so informs the partner physician.

O.C. 84-2018, s. 10.

11. Despite section 9, a nurse practitioner specialized in primary care in an isolated region facility may

(1)  perform advanced care in cardiovascular life support, pediatric advanced life support, neonatal advanced life support and advanced trauma life support;

(2)  perform an emergency delivery and treat postpartum hemorrhages; and

(3)  provide treatment for intoxication.

A nurse practitioner specialized in primary care in an isolated region facility must perform the activities provided for in subparagraphs 1 to 3 of the first paragraph provided that the nurse holds an attestation issued by the Ordre des infirmières et infirmiers du Québec according to which the nurse has successfully completed a 9-week clinical training structured as follows:

(1)  5 weeks of emergency care in a hospital centre, operated by an institution, with a high-volume emergency department;

(2)  2 weeks of pediatric emergency care in a hospital centre, operated by an institution, with a high-volume emergency department;

(3)  2 weeks in the delivery room in a hospital centre, operated by an institution, which offers high-volume obstetric services.

In addition, to perform an activity provided for in subparagraph 1 of the first paragraph, the nurse must hold a corresponding attestation, that is,

(1)  an attestation in Advanced Cardiovascular Life Support (ACLS) issued by the Heart and Stroke Foundation of Canada, in accordance with the standards and guidelines established jointly by the Foundation and by the International Liaison Committee on Resuscitation;

(2)  an attestation in Pediatric Advanced Life Support (PALS) issued by the Heart and Stroke Foundation of Canada, in accordance with the standards and guidelines established jointly by the Foundation and by the International Liaison Committee on Resuscitation;

(3)  an attestation in neonatal resuscitation issued by the Canadian Paediatric Society; or

(4)  an attestation in trauma nursing care (Trauma Nursing Core Course (TNCC)) issued by the National Emergency Nurses Association (NENA, Canada) or the Emergency Nurses Association (ENA, United States).

During the training period provided for in the second paragraph, the specialized nurse practitioner may, in the presence of a physician, perform the activities required to complete the training.

O.C. 84-2018, s. 11.

DIVISION II GENERAL TERMS AND CONDITIONS

O.C. 84-2018, Div. II.

12. A specialized nurse practitioner must perform the activities provided for in section 4 in partnership with a physician who practises in the fields in which the nurse practises. The partnership must be recorded in a written agreement.

The partner physician who practises in physical locations separate from those of the specialized nurse practitioner must establish collaboration mechanisms that ensure continuity of care.

A partnership may be established with more than 1 physician to cover all the activities performed by a specialized nurse practitioner. A partnership may also be established with one or more departments and with one or more clinical services of a hospital centre operated by an institution.

O.C. 84-2018, s. 12.

13. The partnership agreement must include, in particular, the following elements:

(1)  the name of the partner physicians collaborating in the agreement;

(2)  the type of clientele served by the specialized nurse practitioner or the type of clientele excluded;

(3)  the services or care offered by the specialized nurse practitioner or those excluded;

(4)  the procedure to follow for the requests for intervention of the partner physician;

(5)  the procedure to follow for the requests for a medical consultation;

(6)  the means of communication between the specialized nurse practitioner and the partner physician;

(7)  the monitoring mechanisms provided for in section 14;

(8)  the process applicable to the revision or amendment of the agreement;

(9)  the term of the agreement and its termination or renewal procedure;

(10)  the rules for the conservation or transfer of records where the partnership agreement ends.

O.C. 84-2018, s. 13.

14. The partner physician must exercise general monitoring of the quality and relevance of the medical activities.

General monitoring by the physician must include the following elements:

(1)  meetings to discuss collaboration mechanisms;

(2)  case discussions selected by the partner physician or the specialized nurse practitioner;

(3)  selection and review of records of the specialized nurse practitioner by the partner physician to evaluate the quality and relevance of the medical activities that the nurse performs;

(4)  evaluation of the prescription of medications, analyses and diagnostic examinations.

The meetings referred to in subparagraph 1 of the second paragraph must take place on a regular basis and may be conducted remotely using technological means.

O.C. 84-2018, s. 14.

15. A specialized nurse practitioner must request the intervention of the partner physician in the following cases:

(1)  the care required by the patient exceeds the nurse’s skills or area of care or is intended for a clientele of another specialty;

(2)  the signs, symptoms or results of diagnostic examinations indicate that the patient’s state of health has deteriorated, and the nurse is no longer able to ensure the follow-up;

(3)  the results expected from the therapy have not been obtained or the therapeutic target has not been achieved, as the case may be, and the patient does not respond to the usual treatment.

In a request for intervention made to the partner physician, the specialized nurse practitioner must state the reason for the request and specify its degree of urgency and the type of intervention desired. After the intervention of the partner physician, the nurse must perform the activities within the limits of the medical treatment plan determined by that physician.

O.C. 84-2018, s. 15.

16. Before prescribing a diagnostic examination, a specialized nurse practitioner must ensure that a result of that examination for the patient is not otherwise available.

O.C. 84-2018, s. 16.

17. A specialized nurse practitioner may not prescribe, adjust or renew cannabis for medical reasons, including its preparations and derivatives.

O.C. 84-2018, s. 17.

18. A specialized nurse practitioner must write prescriptions in accordance with the provisions applicable to individual prescriptions of the Règlement sur les normes relatives aux ordonnances faites par un médecin (chapter M-9, r. 25.1).

O.C. 84-2018, s. 18.

19. Except under special circumstances, a specialized nurse practitioner may not perform the activities provided for in section 4 in the emergency department of a hospital centre operated by an institution.

O.C. 84-2018, s. 19.

CHAPTER IV ADVISORY COMMITTEE

O.C. 84-2018, c. IV.

20. An advisory committee on the practice of specialized nurse practitioners is established.

The committee’s mandate is to

(1)  examine generally the quality of the clinical practice of specialized nurse practitioners in the various classes of specialization, in particular with respect to

(a)  the quality of the prescription;

(b)  the quality of interventions; and

(c)  the quality of interprofessional collaboration;

(2)  recommend new clinical practices or improvements to respond to scientific developments and new conclusive data;

(3)  make recommendations to the board of directors of the Collège des médecins du Québec and to the board of directors of the Ordre des infirmières et infirmiers du Québec on the terms and conditions of practice of specialized nurse practitioners and on the amendments to be made to the regulations involving specialized nurse practitioners; and

(4)  analyze any other issue related to the practice of specialized nurse practitioners and formulate opinions.

O.C. 84-2018, s. 20.

21. The committee is composed of the following 11 members:

(1)  1 representative of the College;

(2)  1 representative of the Order;

(3)  1 partner physician in acute care appointed by the College;

(4)  1 partner physician in primary care appointed by the College;

(5)  1 nurse practitioner specialized in primary care appointed by the Order;

(6)  1 nurse practitioner specialized in neonatology appointed by the Order;

(7)  1 nurse practitioner specialized in adult care appointed by the Order;

(8)  1 nurse practitioner specialized in pediatric care appointed by the Order;

(9)  1 nurse practitioner specialized in mental health appointed by the Order;

(10)  1 specialized nurse practitioner appointed by the Order with teaching responsibilities in a university training program for the practice of specialized nurse practitioners;

(11)  1 representative of the Direction nationale des soins et services infirmiers of the Ministère de la Santé et des Services sociaux.

The committee may retain the services of any person deemed necessary to achieve its mandate.

O.C. 84-2018, s. 21.

22. The quorum of the committee is 6 members, including 3 specialized nurse practitioners, 1 partner physician and the representatives of both orders.

O.C. 84-2018, s. 22.

23. The members of the committee are appointed for a 3-year term and remain in office until they are re-appointed or replaced.

O.C. 84-2018, s. 23.

CHAPTER V SPECIALIZED NURSE PRACTITIONER STUDENTS AND CANDIDATES

O.C. 84-2018, c. V.

24. A specialized nurse practitioner student may perform the activities provided for in section 4 if the student complies with the terms and conditions prescribed by Chapter III, subject to the following modifications:

(1)  the student performs the activities in a training environment determined pursuant to section 25 of the Regulation respecting the committees on training of the Ordre des infirmières et infirmiers du Québec (chapter I-8, r. 11), under the supervision of a specialized nurse practitioner or a physician, who is physically present;

(2)  sections 12 to 14 do not apply to a specialized nurse practitioner student;

(3)  for the purposes of section 15, the following physicians are considered a partner physician of a specialized nurse practitioner student:

(a)  the physician who supervises the student;

(b)  the partner physician of the specialized nurse practitioner who supervises the student;

(4)  the performance of those activities is required to complete the program in which the student is registered or, where appropriate, to complete a training period or training for the recognition of an equivalence.

O.C. 84-2018, s. 24.

25. A specialized nurse practitioner candidate may perform the activities provided for in section 4 if the candidate complies with the terms and conditions prescribed by Chapter III, subject to the following modifications:

(1)  the candidate performs the activities

(a)  in a centre operated by an institution where a director of nursing care has been appointed; or

(b)  in a medical office, medical clinic, dispensary or other place offering primary care, to the extent that the candidate is employed by an institution where a director of nursing care ensures the supervision of care provided by the specialized nurse practitioner candidate;

(2)  the candidate performs the activities under the supervision of a specialized nurse practitioner or a physician, who practises in the candidate’s area of care and is physically present;

(3)  sections 12 to 14 do not apply to a specialized nurse practitioner candidate;

(4)  for the purposes of section 15, the following physicians are considered a partner physician of a specialized nurse practitioner candidate:

(a)  the physician who supervises the candidate;

(b)  the partner physician of the specialized nurse practitioner who supervises the candidate.

O.C. 84-2018, s. 25.

CHAPTER VI TRANSITIONAL AND FINAL

O.C. 84-2018, c. VI.

26. A nurse practitioner specialized in primary care who obtained the diploma giving access to the specialist’s certificate before 1 September 2017 or who, before that date, was registered in a program of studies leading to a diploma giving access to the specialist’s certificate must, to perform the activities provided for in section 4 in a residential and long-term care centre operated by an institution, undergo training recognized by the Ordre des infirmières et infirmiers du Québec.

The same applies to a nurse practitioner specialized in primary care who, before 8 March 2018, obtained an equivalence of diploma or training in accordance with the Règlement sur les normes d’équivalence de diplôme ou de la formation aux fins de la délivrance d’un certificat de spécialiste d’infirmière praticienne spécialisée (chapter I-8, r. 15.2).

The training provided for in the first paragraph, which lasts 35 hours, specifically focuses on the elderly and includes the following: advanced clinical evaluation, advanced physiopathology and advanced pharmacology. At least 10 hours focus on the elderly who present behavioural and psychological symptoms of dementia.

O.C. 84-2018, s. 26.

27. The advisory committee on the practice of specialized nurse practitioners is composed of 9 members until the Ordre des infirmières et infirmiers du Québec appoints a nurse practitioner specialized in pediatric care and a nurse practitioner specialized in mental health to the committee.

During that period, the quorum of the committee is 5 members, including 2 specialized nurse practitioners, 1 partner physician and the representatives of both orders.

O.C. 84-2018, s. 27.

28. This Regulation replaces the Regulation respecting the activities contemplated in section 31 of the Medical Act which may be engaged in by classes of persons other than physicians (chapter M-9, r. 13).

O.C. 84-2018, s. 28.

29. (Omitted).

O.C. 84-2018, s. 29.

Schedule I

(s. 2, par. 1)

1. A primary care facility situated in the Basse-Côte-Nord territory and managed by the Centre intégré de santé et de services sociaux de la Basse-Côte-Nord.

2. A primary care facility situated in the territory of Nunavik and managed by the Inuulitsivik Health Centre or the Tulattavik Health Centre of Ungava.

3. A primary care facility situated in the James Bay territory and managed by the Cree Board of Health and Social Services of James Bay.

4. A dispensary serving First Nations communities and situated in the following regions:

(1)  Basse-Côte-Nord;

(2)  Minganie;

(3)  Caniapiscau;

(4)  Haute-Mauricie.

5. A dispensary managed by Health Canada’s First Nations and Inuit Health Branch and situated in the following regions:

(1)  Haute-Gatineau (Algonquins of Barrière Lake);

(2)  Témiscamingue (Long Point First Nation).

O.C. 84-2018, Sch. I.