Practice Notes is an educational tool designed to help Ontario social workers, social service workers, employers and members of the public gain a better understanding of recurring issues dealt with by the Professional Practice Department and the Complaints Committee that may affect everyday practice. The notes offer general guidance only and College members with specific practice inquiries should consult the College, since the relevant standards and appropriate course of action will vary depending on the situation.
Social workers and social service workers play an integral role in supporting clients who live with mental health and substance use issues. College members must have a wide range of knowledge and skills when working with these clients, who may have complex needs. Members may be serving clients who have histories of trauma, are experiencing homelessness, or are involved in the criminal justice system, among other challenges.
Increasingly, the opioid crisis and the risk of death due to overdose have permeated all levels of society, and consequently directed public policy in a number of ways. When working with clients, College members must be aware of the serious and significant risk of overdose. The risk of overdose exists when working with any client group, however, members who work in mental health and substance use settings can expect that they will at some point encounter clients who are overdosing.
In October 2016, in response to the opioid crisis, the Ministry of Health and Long-Term Care expanded public access to Naloxone by making it available without a prescription at pharmacies and Public Health Units, to opioid users and friends and family members of users. Naloxone (also known by its brand name Narcan) is a medication used to treat the effects of opioid overdose and can be administered through intra-nasal spray or intra-muscular injection.
Controlled acts
Administering a substance by inhalation or injection is a controlled act under the Regulated Health Professions Act, 1991 (RHPA). College members do not have the authority to perform this controlled act under the RHPA. Additionally, the educational background of social workers and social service workers does not typically include pharmacology and other areas of study needed to perform this controlled act safely.
Members who work in mental health and substance use settings may have competence in some medication practices, such as delivering or providing medication to clients when it is due, however administering a substance to clients by injection or inhalation would not typically be considered appropriate for members to do.1
Only those regulated health professionals where their health profession Act authorizes them to perform the controlled act (e.g. a physician, nurse, pharmacist) have the authority to perform this controlled act. Another regulated health professional or other person is authorized to perform a controlled act if it has been delegated to them by a member of a regulated health profession college where the health profession Act authorizes members of such profession to perform the controlled act.
The RHPA also provides exceptions under which a controlled act may be performed by a person who is not authorized by the RHPA under their health profession Act or by delegation of the controlled act. One of the exceptions is if the controlled act is done in the course of giving first aid or temporary assistance in an emergency.
Delegation of controlled acts
Delegation is a formal process whereby a regulated health professional authorized to perform a controlled act procedure under their health profession Act transfers the authority to perform that controlled act procedure to another individual who would not otherwise have that authority. A delegation may be conferred or established through a direct order or medical directive.2 A direct order is client specific, whereas a medical directive is given in advance and enables a person to perform a procedure for a number of clients when specific conditions are met and specific circumstances exist.3
There are a number of factors to be considered in assessing the appropriateness of delegation of a controlled act procedure.4 It is key that the person to whom a controlled act procedure is delegated is competent to perform the procedure before the authority to perform the procedure is delegated to them.5
The College’s Practice Guidelines for Medication Practices indicate that:
Except for the controlled act of psychotherapy, social workers and social service workers are not authorized to perform and may not perform any other controlled act unless it has been delegated to the social worker or social service worker by a member of a regulated health profession College where the health profession Act authorizes members of such profession to perform the controlled act. The OCSWSSW does not usually consider it appropriate for its members to accept delegation of the controlled act of dispensing a drug or administering a substance (including a drug) by injection or inhalation.6
As stated above, College members do not have the authority to perform the controlled act of administering a substance by inhalation or injection. Under the RHPA, a controlled act can be delegated by a regulated health professional who is authorized to perform a controlled act procedure under their health profession Act. Under the RHPA, a controlled act can also be performed in the course of providing first aid or temporary assistance in an emergency.
With respect to the administration of Naloxone, which is administered through intramuscular injection or by intra-nasal spray, College members should consider a number of questions:
- The purpose of the administration of Naloxone is to prevent overdose deaths. However, a member’s practice environment (which includes the client population, the types of services provided and the chances of unpredictable events occurring) may be a context where a member is expected to administer Naloxone in the course of their role in that practice (e.g. a supervised injection site). In such situations, there could be a debate about whether responding to a frequent or expected occurrence fits within the emergency exception under the RHPA. What steps can a member take to mitigate that risk?
- What steps can a member take to ensure that a delegation is in place?
- Where there is a delegation in place, how does a member ensure that they are competent to administer Naloxone safely and effectively and to manage the outcome of the administration?
- If a member finds themselves in circumstances where a client or other individual is experiencing an opioid overdose and there is no delegation in place, are there steps that a member can take to ensure that they are competent to administer Naloxone safely and effectively?
Consider the following scenarios:
Scenario 1
A member works at a homeless shelter. Many of the clients use substances, and while not allowed to use on the premises, clients may nevertheless do so on occasion. Several clients have overdosed in or near the shelter, and a formal delegation was put in place for staff to administer Naloxone, either through injection or inhalation. The delegation process outlined the ongoing training process in which all staff would need to participate, as well as all of the steps to be followed during and after a potential overdose. The College member called the Professional Practice Department to find out if the Standards of Practice allowed them to administer Naloxone when there was a formal delegation in place.
Scenario 2
A member works on a community mental health support team. As part of their role, they go into the community and visit clients in their homes. There are many aspects to the member’s role, including delivering medications to clients and supporting them in their psychosocial functioning. The member’s workplace has determined that the community mental health team has a high likelihood of encountering clients who have overdosed, as they are visiting clients in their homes and are a regular presence in the community. The organization provided one-day training and distributed Narcan kits to all staff. There is no formal delegation or ongoing training in place for the administration of Naloxone. The member called the Professional Practice Department as they do not feel that they are competent to administer Naloxone, either by injection or inhalation. The member is unclear about how to proceed.
In both scenarios it is anticipated that, due to the practice setting and the members’ roles, they will be confronted with client overdoses in which they will be expected to administer Naloxone as part of their role. It is possible that the RHPA exception that allows for the performance of controlled acts in emergency situations may not apply, in which case a delegation by a regulated health professional authorized to perform the controlled act should be in place in order for the members to administer Naloxone. This circumstance highlights the need for “College members [to] maintain current knowledge of policies, legislation, programs and issues related to the community, its institutions and services in their areas of practice” (emphasis added).7
In the second scenario, without a formal delegation in place, the member may find themselves in conflict with the Standards of Practice. The Standards of Practice state that “College members are responsible for being aware of the extent and parameters of their competence and their professional scope of practice and limit their practice accordingly.”8 They also provide that “…an employer may require a social worker or social service worker to perform activities that are not described in their scope of practice provided that the College member is permitted by law to perform those activities and the College member is competent to do so (emphasis added).9
The Standards of Practice also state that “(i)f there is a conflict between College standards of practice and a College member’s work environment, the College member’s obligation is to the “Ontario College of Social Workers and Social Service Workers Code of Ethics” and the “Standards of Practice Handbook.””10 The member may need to “advocate for workplace conditions and policies that are consistent with the Code of Ethics and Standards of Practice of the Ontario College of Social Workers and Social Service Workers. A social worker or social service worker will use professional judgement in determining how to advocate. Such advocacy may take the form of documenting concerns and discussing them with a supervisor or manager, or other key person in the organization.”11
If the member in the second scenario determined that they should not administer Naloxone in their workplace due to the absence of a formal delegation, they would need to put a plan in place for clients to receive Naloxone treatment from another professional who is authorized to administer Naloxone and competent to do so. The Standards of Practice state that members must “assist potential clients to obtain other services if members are unable or unwilling, for appropriate reasons, to provide the requested professional help.”12
The dilemma of being in conflict between the College’s Standards of Practice and a member’s work environment is addressed in further detail in the previous Practice Notes, “But “They” Told Me To! Owning Your Professional Accountability.”
Another important consideration for the members in both scenarios is competence. A formal delegation process meets legislative and professional requirements, and provides direction (through mechanisms such as a Performance Readiness Assessment) as to how members can develop and maintain their competence in an ongoing way. The member in the first scenario has a formal delegation, which describes how the member can obtain and maintain competence to administer Naloxone.
The member in the second scenario does not have a delegation in place, did not feel that the training they received on the use of a Narcan kit was adequate, and does not have an ongoing plan to continue to develop their competence to administer Naloxone. The Standards of Practice state that “College members are committed to ongoing professional development and maintaining competence in their practice”13 – a standard which must be emphasized when members are performing a controlled act that is not typically considered appropriate for College members.
The Standards of Practice also state that it is a College member’s responsibility to be “aware of the extent and parameters of their competence and their professional scope of practice and limit their practice accordingly. When a client’s needs fall outside the College member’s usual area of practice, the member informs the client of the option to be referred to another professional.”14 Members must always determine whether or not they are competent to provide a particular treatment or intervention. At times, they may feel that they are unprepared or not fully competent, perhaps because the training they received was inadequate. Regardless of the level of training they receive, members may feel that they will never be sufficiently skilled or prepared to perform a particular intervention. In these instances, members must use their professional judgment to determine whether or not they are the appropriate professional to provide the service.
In the second scenario described above, the member did not feel that they were adequately prepared to administer Naloxone. As discussed above, the member should communicate this to their supervisor, and make alternate plans to ensure clients’ needs are met.
Administration of Naloxone in an emergency
So far, these Practice Notes have focused on the circumstances in which it was expected that the member’s role in their practice would involve the administration of Naloxone. As previously discussed, the RHPA provides exceptions under which controlled acts may be performed in the absence of authority under a health profession Act or delegation; these situations include in the course of providing first aid or temporary assistance in an emergency. For example, a member may find themselves in a circumstance where they are responding to a client or other individual who appears to be having an opioid overdose and the administration of Naloxone is not an expected part of their role in that practice.
Consider the following:
Scenario 3
A member who worked with postpartum mothers at a community health centre decided of their own accord to obtain a Narcan kit from Public Health. The member received training through Public Health on the administration of the drug, and decided that it would be a good idea to carry it with them. The member was neither required nor expected to administer Naloxone by their employer or as a result of their role at the community health centre. In the course of their practice, while out in the community, the member came across an individual who was displaying signs of an opioid overdose. The member administered Naloxone to the individual and called for emergency services.
In this scenario, the member administered Naloxone as they had been trained and provided first aid and temporary assistance in an emergency, as permitted under the RHPA. While the member in Scenario 3 is not expected as part of their role to administer Naloxone, they would be well advised to maintain their competence with respect to using a Narcan kit before administering Naloxone.15
Conclusion
As a result of the opioid crisis, members may increasingly find themselves in practice situations in which the administration of Naloxone by inhalation or injection is expected as part of their role. The complex issues around the administration of Naloxone highlight the ongoing need for members to continually be aware of the issues, policies and legislation that impact their practice, so that they can ensure that they are practising professionally, ethically and competently.