Introduction

Dispensing drugs is, and has traditionally been, part of nurses’ roles in a variety of settings and situations. Under the Regulated Health Professions Act (RHPA), nurses must be delegated the authority to perform this controlled act. At its September meeting, Council sanctioned the delegation of dispensing to nurses from pharmacists. The College of Nurses of Ontario (CNO) and the Ontario College of Pharmacists have worked together to develop the following guidelines for delegation of dispensing.

Under the RHPA, only authorized health professionals can perform a "controlled act" as defined in section 27. Controlled act #8, which relates to dispensing drugs, reads:

"prescribing, dispensing, selling or compounding a drug as defined in subsection 117 (1) of the Drug and Pharmacies Regulation Act, or supervising the part of a pharmacy where such drugs are kept."

This controlled act is authorized in varying degrees to pharmacists, physicians, and dentists. Members of OCP are authorized to dispense, sell, or compound a drug or supervise the part of a pharmacy where drugs are kept. Members of the College of Physicians and Surgeons of Ontario (CPSO) are authorized to prescribe, dispense, sell, or compound a drug. Members of the Royal College of Dental Surgeons are authorized to prescribe or dispense drugs. Members of CNO are not authorized to perform any part of this controlled act.

Despite the lack of authority in legislation, dispensing is an integral part of nurses’ roles in a variety of settings and situations. In acute care settings, nurses working in emergency rooms and day surgery units dispense drugs to clients to take home. Nurses in a variety of settings prepare leave of absence (LOA) or pass medications from ward stock or unit dose. In community health, nurses dispense oral contraceptives and other drugs in a variety of clinics. Nurses who dispense drugs as part of their role must be delegated the authority to continue this practice. CNO and OCP have worked together to identify the process for delegation of dispensing by pharmacists to nurses. (Note: CNO and CPSO are currently discussing CNO’s request for delegation of dispensing by physicians to nurses in settings where there is no pharmacist.)

What is "dispensing"?

Dispensing includes the selection, preparation, and transfer of one or more doses of a drug to a client or his or her representative for administration. The process of dispensing involves both a technical and a cognitive component. The technical component includes:

• receiving and reading the prescription;
• adjusting an order according to approved policy (i.e. therapeutic interchange in institutions/health care facilities);
• order entry;
• selecting the drug or determining the product to dispense;
• checking the expiry date;
• reconstituting a product;
• repackaging the drug;
• labelling a product;
• final physical check for accuracy of finished product;
• maintaining but not interpreting medication profiles; and
• maintaining, preparing and operating equipment.

The cognitive component includes assessing the therapeutic appropriateness of a prescription and making a recommendation to a prescriber, or developing the formula for a drug that needs to be specifically prepared by a pharmacist.

What is not considered "dispensing"?

Activities that fall within administration of medications, repackaging of medications, and providing medications to clients are not considered dispensing.

Administration

There is considerable overlap between the technical component of dispensing a drug and preparing a drug for administration. Administration involves one individual (the nurse) preparing a dose of a drug and providing it to a client at the time the medication is due.

There is also overlap between the cognitive component of dispensing and the cognitive component of administering. For example, assessing the appropriateness of a prescription, and providing appropriate health teaching or drug information to a client occur both when dispensing and administering a drug.

Repackaging already dispensed products

When a drug has been dispensed by a pharmacist to an individual, the product, usually in a blister pack, vial or unit dose package, is labelled with the drug name, dose, frequency, and the client’s name. Dispensing a drug to an individual occurs only once, therefore it is considered repackaging and not dispensing to:

• fill a mechanical aid or alternate container from the client’s own blister pack or prescription bottle to facilitate self-administration or administration by another care provider (Note: Care provider, in this context, means family member or unregulated care provider; it does not include another RN or RPN.)
• repackage drugs from a client’s own blister pack or vial for an LOA

Note: Repackaging drugs could require that the product be labelled in an appropriate manner, depending on the situation or the setting.

Providing drugs to a client

Dispensing does not include:

• giving a client LOA medications prepared by a pharmacy, or
• giving a client his or her blister pack or prescription bottle to take on an LOA

What is compounding?

Compounding is the act of combining two or more elements to create a distinct pharmaceutical product. Examples include preparing non-sterile topical and oral preparations as well as intravenous mixtures such as total parenteral nutrition (TPN). Compounding is not authorized to nurses. However, delegation is not required when combining elements to prepare a drug for administration. For example, the reconstitution of intravenous drugs, mixing two types of insulin in a syringe, or combining Milk of Magnesia and Cascara does not require delegation when performed by nurses as part of preparation of a drug for administration. Compounding in other circumstances (e.g. bulk compounding of a product for agency-wide distribution) is a pharmacist's role; it is not an appropriate role for nurses.

What is delegation?

Delegation is the transfer of authority from a regulated health professional who is authorized to perform a particular controlled act to an individual who is not. Members of a regulated health care profession may delegate certain aspects of their profession's authorized acts according to established protocols or policy. For delegation to take place, the regulatory colleges must agree on the conditions and process for delegation.

When is delegation of dispensing required?

Delegation is required for nurses to perform any of the following activities as part of their role.

• Preparing (packaging) LOA or pass medications from a ward stock or unit dose supply.
• Filling a mechanical aid or alternate container from a ward stock or unit dose supply for client self-administration or for another care provider to administer. (Note: Care provider, in this context, means family member or unregulated care provider; it does not include another RN or RPN.)
• Providing clients with several doses of medication (taken from a stock supply) for self-administration (e.g. giving either the entire prescription or several doses of a medication to a client in an emergency department or providing oral contraceptives in a clinic to take home).
• Repackaging large volume ward stock into smaller containers for an alternate ward stock supply.
• Providing clients with sample prescription drug packs.

The decision about whether dispensing drugs to clients is an appropriate role for nurses in a particular practice setting should be made jointly by administration, the profession that is delegating (pharmacy) and the profession accepting delegation (nursing). When considering delegation of dispensing, the standard of care or outcome for the client should be the same regardless of whether a nurse or a pharmacist performs the act. Delegation is not appropriate when the same standard of care cannot be achieved.

The following factors must be considered to determine whether delegation of dispensing is appropriate in the practice setting:

• the complexity of the clients' conditions,
• the range and type of drugs to be dispensed, and
• the knowledge required to dispense.

A process for delegation must be established within the practice setting. Policies and procedures are needed which identify:

• who the delegator is (the pharmacist responsible),
• the nurses who have been delegated the authority to dispense,
• the process for delegation, and
• guidelines for dispensing specific types of drugs.

What is the role of the pharmacist in delegating dispensing to nurses?

OCP authorizes pharmacists to delegate only the technical component of dispensing and not the cognitive component. OCP and CNO recognize the overlap in the cognitive component between nurses and pharmacists in a number of areas (e.g. health teaching).

All pharmacists are permitted by OCP to delegate dispensing to nurses. However, the delegating pharmacist must have sufficient knowledge and expertise to ensure that delegation is done safely and effectively. It is not necessary for the delegating pharmacist to be an employee of the practice setting, provided there is a formal documented relationship between the pharmacist and the practice setting which outlines the role and accountability of the pharmacist (i.e. in a contract or consulting capacity).

The delegating pharmacist is accountable for:

• approving the act of dispensing by nurses in specific practice areas;
• developing guidelines/protocols for dispensing specific drugs that include information about packaging, labelling, storage, instructions for administration, etc., that are consistent with the standards acceptable to the profession of pharmacy;
• establishing a mechanism for assessing competence of the individuals accepting delegation;
• establishing and maintaining quality control measures to ensure competent dispensing;
• ensuring that all policies and procedures related to the delegation authority, process, and tasks are documented.

Any pharmacist who is asked to delegate a function with which he or she is uncomfortable has the right to refuse to delegate. For more information on the responsibilities of the pharmacist who delegates, see OCP’s Protocol for Delegation of Dispensing in Health Care Facilities.

What is the role of the nurse in accepting delegation of dispensing?

Nurses may accept delegation of dispensing when certain conditions have been met. That is, they are accountable for:

• knowing that the conditions for dispensing jointly identified by OCP and CNO have been met;
• reasonably believing that the delegator is competent to perform and delegate dispensing of the particular drug(s);
• having the knowledge, skill, and judgement to dispense the drug(s) safely, effectively, and ethically;
• following established guidelines/protocols for dispensing specific drugs; and
• determining that the client’s condition warrants dispensing the drug(s), having considered,
• the known risks and benefits of dispensing the drug(s) to the client, and
• other factors specific to the situation.

It is anticipated that in most circumstances, registered nurses (RNs) will dispense drugs as part of their role. In circumstances where a limited range of drugs are dispensed and the cognitive requirements of the role are not highly complex, it may be appropriate for a registered practical nurse (RPN) to assume this function. For example, an RPN may dispense in an ambulatory care department where a post operative-eye drop medication is dispensed to all clients with the same directions for administration. RPNs who accept delegation of dispensing must administer medications as part of their role.

What happens when a pharmacist is not available to delegate?

It is expected that in almost all instances, delegation of dispensing will be from a pharmacist to a nurse. In practice settings where both pharmacists and physicians are available, it is expected that dispensing will be delegated by a pharmacist rather than a physician. Small hospitals with no on-site pharmacist need to ensure that a consultant pharmacist is available should a nurse be asked to assume a role that includes hospital-wide dispensing.

CNO recognizes that nurses employed in public health or community clinics who dispense a range of drugs might not have access to consultant pharmacists. In these selected instances, delegation of dispensing by a physician is appropriate. CNO has made a formal request to the College of Physicians and Surgeons for delegation of dispensing by physicians to nurses in these settings. Further information will be published as it becomes available.

This article was prepared jointly by Deanna Laws, OCP Director of Programs; Jim Gay, OCP Manager, Pharmacy Practice Programs; Joan Edwards, CNO Director, Nursing Practice; and Sylvia Rodgers, CNO Nursing Practice Advisor. (1996)