Regulatory Guidance

 Delegation in the Practice of Naturopathy
Naturopathic Doctors in Ontario have the authority to delegate certain controlled acts. A delegation is made when a regulated health care professional who has the authority and the ability to perform a controlled act transfers that authority to a person who otherwise would not be able to perform the procedure. For example, when a Naturopathic Doctor teaches a member of staff to perform intramuscular vitamin B12 shots on patients, the ND has delegated the controlled act of administering a substance by injection.

In order to ensure that a controlled act is delegated safely there are criteria that must be met. Only demonstrating how a B12 i.m. injection is performed does not meet all the criteria. This article will outline the criteria that the ND is responsible for when making, as well as when accepting, a delegation.

Only certain controlled acts can be delegated by an ND in Ontario, they are as follows:
  • putting an instrument, hand or finger beyond the labia majora but not beyond the the cervix,
  • putting an instrument, hand or finger beyond the anal verge but not beyond the rectal-sigmoidal junction,
  • administering a substance by inhalation,
  • administering a substance by injection,
  • performing procedures involving moving the joints of the spine beyond the individual's usual physiological range of motion using a fast, low amplitude thrust,
  • taking blood samples from veins or by skin pricking for the purpose of prescribed naturopathic examinations on the samples, and
  • prescribing, dispensing, compounding and selling a drug designated in regulations.

The controlled acts that NDs cannot delegate even though they have the authority to perform them are:

  • communicating a naturopathic diagnosis, and
  • performing acupuncture.
Section 22 of the General Regulation made under the Naturopathy Act, states that a member shall not delegate the controlled act of communicating a naturopathic diagnosis. This is based on the premise that a naturopathic diagnosis can truly only be communicated by a Naturopathic Doctor.

Acupuncture is authorized to the profession through an exemption made in a regulation under the Regulated Health Professions Act (RHPA) rather than directly in the naturopathy Act. In the case of a controlled act being authorized through an exemption, the RHPA does not allow for delegation of that controlled act.

The criteria for making and accepting a delegation can be found in Part III of the General Regulation and the Standard of Practice for Delegation.

Making a Delegation

In order to make a delegation the ND (the delegator) must first have the authority to perform the controlled act and must also have the knowledge, skill and judgment to perform that controlled act. For example, an ND who regularly uses manipulation as a treatment for patients can delegate this controlled act. A ND who does not provide manipulation or due to some physical disability cannot perform manipulation as a treatment for patients, cannot delegate this controlled act. Even though the ND has the authority to perform it, he or she is considered not to have the skill to perform it.

An ND cannot delegate to just anyone. NDs can delegate to:
  • a health care provider who has a professional relationship with the patient,
  • a person in the patient's household, or
  • a person who routinely provides assistance or treatment to the patient.
An ND would never delegate to another ND. All NDs in Ontario have the authority to perform the above controlled acts and so do not need that authority given to him or her through a delegation. In the case of administering a substance by inhalation or injection, or prescribing, dispensing, compounding or selling a drug, the College has a standard of practice made in regulation requiring the successful completion of courses and examinations in IVIT and prescribing in order to exercise the authority of performing these controlled act. Therefore, only an ND who has met these standards can perform these acts and cannot accept a delegation from another ND as a way of circumventing the regulation.

An ND who cannot perform IVIT has the option to refer a patient to an ND who has completed the required courses and examinations and so is able to provide IVIT.

A referral is different from a delegation in that the ND is ensuring the patient receives the needed health services by sending them to a health care practitioner who already has the authority and ability to perform the controlled acts that may be needed to assess and/or treat.

The ND making the delegation must have a naturopath-patient relationship with the person on whom the controlled act will be performed and have determined that it is in the best interests and needs of the patient, not of the ND, that the delegation occur.

The delegator is expected to take reasonable steps to ensure that the delegatee has the knowledge, skill and judgment to perform the controlled act safely and ethically. The steps that are required may be different depending on the delegatee and whether or not he or she is a member of another regulated health profession. It is the responsibility of the ND to determine what training for the delegatee is necessary.

It is also the responsibility of the ND making a delegation to ensure that the delegatee can accept the delegation.There may be restrictions or additional requirements placed on other regulated health care practitioners when accepting a delegation. For example, a Registered Nurse cannot accept a delegation from an ND unless there is an order in place from a Medical Doctor specific to the procedure.

Additional criteria include that the delegator puts in place any necessary conditions as well as making sufficient safeguards and resources available to the delegatee to ensure that the controlled act is performed safely and ethically. In order to ensure proper management of any adverse event that may occur, a communication plan between the delegator and the delegatee must also be in place.

The responsibility for the safe and ethical performance of the controlled act rests with the delegator, and as such, if the delegator has reasonable grounds to believe that the delegatee is no longer able to perform the controlled act safely and ethically he or she shall stop delegating the controlled act to that individual and take steps to ensure that any delegated controlled acts not completed are not performed.

While the delegation can be made orally or in writing, there are record keeping requirements. These include that a written record of the particulars of the delegation, including the communication plan, are available in the place where the controlled act is to be performed as well as in the patient record.

At a minimum the particulars of a delegation must include the date of the delegation, names of the delegator and delegatee and any conditions that applied. 

A member who has a controlled act delegated to him or her is not allowed to then delegate that controlled act to another person.

Accepting a Delegation

Naturopathic Doctors in Ontario can also accept a delegation from a health care professional who has the authority to make a delegation.

The criteria that must be met when accepting a delegation are similar to those of making a delegation. The ND who is accepting a delegation has the same responsibility as when making a delegation to ensure that the criteria are met.

When accepting a delegation the member ensures that he or she:

  • has the knowledge, skill and judgment to perform the controlled act safely and ethically,
  • has a naturopath-patient relationship with the patient,
  • has considered whether performing the controlled act is appropriate, bearing in mind the best interests and needs of the patient,
  • is satisfied that there are sufficient safeguards and resources available, 
  • has no reason to believe that the delegator is not permitted to make the delegation
  • has ensured that any conditions in place have been met, and,
  • has ensured that a record of the particulars of the delegation are in the patient file or available in the place where the controlled act is to be performed.

For all criteria and information regarding the making and accepting of a delegation please refer to Part III of the General Regulation and the Standard of Practice for Delegation.

 

Additional resources:

 

Standard of Practice for Delegation

General Regulation (O. Reg. 168/15)

Referrals and Consultations Guideline