Original Article

Article original

Understanding the role

of nurse practitioners in Canada

Andrew Worster, MD, The practice of medicine and nursing continues to evolve as a result of changes in
CCFP(EM), MSc, knowledge, technology and health care needs. New areas of specialization have devel-
FCFP* oped and, in particular, the roles and duties of registered nurses have been expanded.
This expansion has enabled nurses with advanced education and skills to function as
Arlene Sarco, RN, independent and interdependent clinicians who practise in partnership with physicians
MSN, ACNP, ENC(C)* and other health care professionals.

Christine Thrasher, La pratique de la médecine et des soins infirmiers continue de se transformer à mesure
RN(EC), MScN, NP,
PhD(c)* de l’évolution du savoir, de la technologie et des besoins en soins de santé. De nou-
velles spécialités ont fait leur apparition et les rôles et responsabilités des infirmières
Christopher Fernandes, autorisées, en particulier, ont pris de l’ampleur. Cette expansion a permis aux infir-
MD, FACEP† mières qui ont fait des études avancées et possèdent des compétences spécialisées de
fonctionner comme cliniciennes autonomes et interdépendantes qui pratiquent en
Elaine Chemeris, RN,
BScN, MN* partenariat avec les médecins et autres professionnels de la santé.

*Emergency and Pre-Hospi-

tal Services, Hamilton
Health Sciences, and
McMaster University,
Hamilton, Ont.
†Faculty of Nursing,
University of Windsor,
Windsor, Ont.
I n these times of complex health
care issues, economic chal-
lenges, escalating health care
costs and limited access to physicians,
alternative models of health care deliv-
ery, such as nurse practitioners (NPs),
of NPs into a strategic health care plan
will be discussed.

Historical perspective

In 1967, the first education program

Correspondence to:
have the potential to improve access to for NPs working in northern nursing
Dr. Andrew Worster, comprehensive and appropriate care stations was started at Dalhousie Uni-
Research Director, services. They are an important consid- versity in Halifax, NS. The 1972
Emergency Medicine, eration for health policy decision-mak- Boudreau Report3 made the implemen-
Hamilton Health Sciences,
McMaster University ers. 1,2 Despite this, NPs remain an tation of the expanded role of the regis-
Medical Centre, 1200 Main underused resource within the health tered nurse (RN) a high priority in
St. W, Hamilton ON care system.1 Canada’s health care system. A joint
L8N 3Z5
In Canada there is discordance with statement on the role of the NP was
This article has been peer respect to titles, educational require- released in 1973 by the Canadian Nurs-
reviewed. ments, legislation, and clinical and legal es Association and the Canadian Med-
responsibilities among regions. This ical Association,4,5 but during the 1980s,
discordance limits the portability of NP education programs across Canada
certification and even the implementa- were obsolete. This is believed to be
tion of NPs in many settings. due to a perceived physician oversup-
The purpose of this article is to pro- ply, lack of remuneration mechanisms,
vide the reader with an explanation of lack of legislation, lack of public aware-
the titles, educational requirements, ness, lack of support from both medi-
legislation and clinical and legal respon- cine and nursing, and, of course, lack of
sibilities of NPs, as well as barriers to funding.6 Despite this unfavourable sit- 89
the effective integration of these nurses. uation, approximately 250 NPs contin-
The recommendations for integration ued to work in Ontario through the
© 2005 Society of Rural Physicians of Canada Can J Rural Med 2005; 10 (2)
 1980s and early 1990s, primarily in community • Registered Nurse–Extended Class (RN[EC])
health centres and in northern nursing stations. In • Acute Care Nurse Practitioner (ACNP)
spite of the failure of the first initiatives, the NP role • Clinical Nurse Specialist/Nurse Practitioner
continues to be promoted by government health (CNS/NP)
care commissions and task forces as a valuable • Nurse Practitioner–Specialist (NP-S)
resource for the delivery of health care, especially in • Specialty Acute Care Nurse Practitioner
the areas of disease and injury prevention, health (SACNP).
promotion and community-based care. Details of
the history of NPs can be found at the Nurse Prac- Education
titioners’ Association of Ontario Web site
(www.npao.org/history.aspx). Currently only 12 of the 66 nursing programs in
Canada offer NP education and certification, the
Definition majority of which are baccalaureate or post-diploma
programs focusing on primary care (PHC NP).
“Nurse practitioner” is a frequently used title to However, this has resulted in NPs with different
identify advance practice nurses (APNs), but it has titles, scopes of function, and levels of educational
no universal definition. The NP role has existed in preparation and certification. In 1994 the Council of
Canada and the US since the 1960s. In its infancy, Ontario University Programs in Nursing, a consor-
the term “nurse practitioner” referred to RNs work- tium of 10 nursing faculties in the province, devel-
ing in ambulatory or outpatient settings such as oped a new PHC NP Program, and the first class
public health, clinics and physician offices. The role graduated in 1996. An emergence of ACNP pro-
has since evolved, and NPs are now typically recog- grams developed for intensive care settings began in
nized as having acquired additional knowledge, 1986 at McMaster University with the training of
skills and expertise in an area of specialty (e.g,. NPs in neonatology. Other acute care NP specialty
neonatology, critical care, diabetes). Advanced training programs have since been developed,
nursing practice synthesizes nursing and medical including those at the universities of Alberta and of
knowledge, with a commitment to client-centred Toronto. Lobbying is currently underway by pro-
care.7 In their expanded roles, NPs may perform fessional nursing associations, regulatory bodies and
tasks that have traditionally been considered the interest groups across the country to standardize all
domain of physicians.8 NP programs at the graduate degree level.
Although it has been in common use in Canada
since the 1970s, the NP title is not protected in rele- Roles
vant Canadian Acts and, therefore, means different
things to different people. The umbrella term The role of the PHC NP involves a community-
“advance practice nurse” is frequently used to refer based scope of practice, often in association with a
to this group and accounts for both the variety of family physician, where advanced decision-making
specialized nursing roles and the additional educa- skills in assessment, diagnosis and care management
tional preparation that each role requires.8 In the are used. The PHC NP provides health care ser-
medical literature these RNs are often collectively vices with a focus on health promotion, prevention,
referred to as “nurse practitioners,” and the term rehabilitation and support care and within the legis-
“nurse practitioner” is the recognized Medical Sub- lated scope of nursing practice, which include the 3
ject Heading (i.e., MeSH) by the National Library Controlled Acts entitled to all RNs in Ontario
of Medicine. Title protection, as well as regulation (Table 1).10 Depending on provincial legislation, the
of NPs, is the responsibility of the provincial and PHC NP is able to provide independent care
territorial nursing regulatory bodies. However, in beyond this scope of general nursing practice.
most provinces there is no restriction on the use of The role of the ACNP involves managing
the title. Therefore, an NP may be one who has patients across all health settings, including the
completed a formal graduate program and has years management of the acutely and critically ill or those
of clinical experience or one who has a diploma in with an exacerbation of chronic health problems.8
nursing and who has learned on the job.6 This role includes providing direct patient care
90 Titles used by NPs in Canada include:9 management by performing in-depth physical
• Primary Health Care Nurse Practitioner assessments, interpreting results of laboratory and
(PHC NP) diagnostic tests, ordering pharmacotherapeutics and
Can J Rural Med 2005; 10 (2)
performing invasive procedures such as insertion of Collection Centre Act. However, the RN(EC) does
arterial or central venous catheters.11 Specialty areas not have the authority to interpret these investiga-
of ACNP practice in the US were initially focused tions; that remains the responsibility of a physi-
on hospital-based care such as critical care, pedi- cian.16
atrics, subspecialties of internal medicine and The RN(EC) is also authorized to prescribe a
surgery, emergency medicine, and many others.12 specific range of drugs provided in a statutory
These specialty areas have since expanded to clinics amendment to the Nursing Act, 1991, made under
and other unique settings such as home care, long- the Expanded Nursing Services of Patients Act,
term care, sports medicine, and tropical medicine.12 1997. Any drugs and/or laboratory tests not on the
Both categories of NPs function under a collabo- list must be ordered by the collaborating physician
rative model of practice involving all members of a but may also be ordered by the nurse through a
health care team. In the absence of provincial legis- medical directive.16 Currently, many PHC NPs per-
lation and regulations, the NPs must work within form diagnostic and prescribing activities under the
existing nursing legislation and under protocols or authority of a physician, often by means of a med-
medical directives defined by the NP and the ical directive. Registration in the Extended Class
employer. This model may or may not be outlined in permits the PHC NP to assume sole accountability
a collaborative practice agreement, which is a legal for these activities. Therefore, it is important for
document defining the NPs’ scope of practice and these NPs to identify themselves by following their
responsibilities, practice protocols and reporting signatures with the initials “RN(EC).”
structure. The collaborative practice agreement is In addition to the above activities, NPs can con-
binding among all parties: the NP, the collaborating sult other health care professionals, including physi-
physician(s), the institution (employer), and/or cians. This consultation or referral can occur at any
departmental head(s), and is not transferable from point in the assessment of the patient or when plan-
one employer or NP to another. ning, implementing or evaluating the patient’s care,
whenever the patient’s condition requires care
Legislation and regulatory issues beyond the scope of practice of the RN(EC). The
degree to which the physician becomes involved
Only 3 Canadian provinces (Ontario, Alberta, and may vary. Consultation may result in the physician
Newfoundland and Labrador) have passed legisla- providing an opinion and recommendation; an opin-
tion supporting the APN role. Alberta and Ontario ion, recommendation and concurrent intervention;
have legislation supporting PHC NPs, and in 1994 or assuming primary responsibility for the care of
the College of Nurses of Ontario approved the new the client (transfer of care).
class of RNs — the Extended Class RN(EC).13,14
Graduates from an Ontario PHC NP program may Medicolegal issues
write the Ontario provincial certification exam for
the RN(EC) designation, which is protected under All health care professionals, including NPs, are
this provincial legislation. In 2001, Newfoundland accountable for their practice and face liability risks
and Labrador became the only province in the
country to have passed legislation supporting Table 1. Controlled acts entitled to all registered nurses in
ACNPs and adopt the title Nurse Practitioner–Spe- Ontario
cialist (NP-S).15 1. Performing a prescribed procedure below the dermis or
There are 3 controlled acts10 authorized to RNs in mucous membrane;
the Nursing Act in Ontario (1991) (Table 1). The 2. Administering a substance by inhalation or injection; and
RN(EC) has the authority to perform 3 additional 3. Putting an instrument, hand or finger
controlled acts: 1) communicating a diagnosis of a • beyond the external ear canal,
disease or disorder, 2) ordering diagnostic ultra- • beyond the point in the nasal passages where they
sound, and 3) prescribing a limited range of drugs. normally narrow,
As well, changes to other acts authorize the • beyond the larynx,
RN(EC) to order specific x-rays (chest, rib, arm, • beyond the opening of the urethra,
wrist, hand, leg, ankle, foot), mammography and •
ultrasonography (abdomen, pelvis, breast), and the •
beyond the labia majoria,
beyond the anal verge, or
91
RN(EC) can order a specific range of 101 laborato-
• into an artificial opening into the body.
ry tests provided in the Laboratory and Specimen
Can J Rural Med 2005; 10 (2)
 related to their health care role. This accountability Evidence
does not preclude physicians from being enjoined as
defendants in a lawsuit, but typically only those The first randomized controlled trial (RCT) com-
found responsible for the adverse outcomes are held paring NPs to physicians was conducted in 1969 in
liable.17 Ideally, all NPs should have personal liabili- a primary care setting.19 Using patient mortality, dis-
ty protection for malpractice claims. Liability pro- ability and dissatisfaction as outcomes, the results
tection for Canadian nurses is provided by the demonstrated that NPs could provide primary
Canadian Nurses Protective Society (CNPS), simi- health care as well as physicians. Canadian primary
lar to the Canadian Medical Protective Association care NP RCTs were the next to be reported.20–22 In
for Canadian physicians. The CNPS is a non-profit addition to establishing the methodology for similar
organization that offers legal liability protection health outcome-based trials, these studies brought
(related to nursing practice) to eligible RNs. As to the forefront the concept of NPs performing
members of a professional association or college that many of the primary care tasks of Canadian family
is a participating member of CNPS, NPs are auto- physicians. They also quantitatively demonstrated
matically eligible for personal occurrence-based an equivalence in patient health outcomes between
professional liability protection; that is, protection the 2 groups.
for whenever the claim is made, as long as the NP Although these trials showed that NPs could
was insured at the time of the occurrence. CNPS function alone in 67% of all patient visits and were
assistance is available up to $2 million for each cost effective in this setting, the single fee-for-ser-
occurrence to a maximum of $3 million per year for vice physician payment model was not conducive to
civil lawsuits, successfully defended criminal universal adoption of NPs in all primary care prac-
charges and alleged breach of statute arising from tices.21 Recently, several multi-centred, RCTs com-
the provision of a professional nursing service. paring NPs to physicians in primary care settings
Whether an NP requires more liability protection have been published.19,23–25 The comparisons have
than the $2 million offered by CNPS is dependent involved resource use and validated measures of
on the legal risk factors inherent in the role. Addi- patient satisfaction and health status.
tional insurance, often in the amount of $5 million, A recent systematic review of 11 trials and 23
is available and is usually claim-based. Additional observational studies examined a) patient and
“tail coverage” insurance, which provides protection provider satisfaction, b) safety and effectiveness,
for claims made during an additional “tail” period, is c) process of care, and d) costs.26 The authors iden-
available for purchase. Inadequate NP malpractice tified few recent RCTs, and the observational stud-
insurance coverage may have an impact on associat- ies were of poor quality. Operational definitions
ed physicians in cases of common care, such that, were vague or inconsistent across the literature, and
“the individual with insurance coverage may become finan- valid and reliable measurement tools were rarely
cially liable for all.”17 used. Despite these limitations, similarities in find-
CNPS statistics reveal that NPs were involved ings were evident in the studies reviewed, and the
in 1.6% of the lawsuits and 2.1% of all occurrences ability to replicate studies and demonstrate consis-
reported to CNPS between 1997 and 2001.18 The tent findings may allow for generalizability.27 The
10-year claims history from the American National authors found that care delivered by NPs in various
Practitioner Data Bank indicates that malpractice primary care settings resulted in higher patient sat-
payments for nurses have been rare (1.7% of all isfaction and quality of care compared with physi-
payments) and NPs were responsible for only 4.7 % cian care, with no difference in health outcomes. No
of all nurse payments.18 differences were found in prescribing patterns, con-
Although some physicians and their associations sultations or referrals. Compared with physicians’
have voiced concerns that working with NPs might patients, NPs’ patients demonstrated equivalent or
increase their risk of liability, other physicians sug- greater 1) compliance with health promotion treat-
gest an added value of having NPs on the team in ment recommendations, and 2) knowledge of their
that NPs mitigate risk because of very good com- health status and treatment plan. NPs spent more
munication skills and their therapeutic relationships time per visit with their patients than did physi-
with patients and families. Therefore, although it is cians, but the average number of visits per patient
92 important to maximize liability protection, it is more was the same. Although the NPs ordered more lab
important to develop a comprehensive risk-manage- tests than did physicians, the average lab cost per
ment strategy for collaborative practice models. NP patient was less.28 In summary, the cumulative
Can J Rural Med 2005; 10 (2)
published research shows that, in all outcomes mea- Currently, one of the greatest barriers to introduc-
sured, NPs performed as well or better than physi- ing the NP role in a national health care strategic
cians. Although NPs frequently spent more time plan is the lack of a concerted and cooperative effort
with patients, it was found that they also provided by all legislative and regulatory bodies to create uni-
patients with more information.24 These combined versally accepted systems of accreditation and licen-
factors may be responsible for the higher patient sure similar to those for Canadian physicians.
satisfaction scores that NPs received.24 This accu- Although a national standardization of NPs is one
mulative evidence does not demonstrate that NPs step in the process of implementing NP roles into a
can replace physicians, but rather that, under spe- national health strategic plan, another is the demon-
cific conditions, they are able to perform a limited stration of conclusive evidence. Finding this evi-
number of tasks usually carried out by physicians. dence involves a comprehensive research program
that uses a variety of research methodologies to
Facilitators and barriers assess the complex and multifaceted components of
health care delivery. The first phase should involve
A comprehensive review of the facilitators and barri- needs-assessment studies for each of the proposed
ers to the integration of NPs into the Canadian areas of NP practice, to determine the most appro-
health care system based on a review of published priate roles for NPs in Canadian health care.31 These
studies can be found in the Report on the Integration of would then be followed by clinical trials assessing
Primary Health Care Nurse Practitioners into the Province patient outcome, patient and coworker satisfaction,
of Ontario.29 Facilitators identified in this review are and cost-effectiveness as it has been demonstrated
categorized as follows: policies and legislation; fund- with primary care studies. Currently, the majority of
ing; practice models; education; evaluation and mea- published clinical trials demonstrating the clinical
surement; and other. The barriers identified are simi- effectiveness of NPs has been conducted at the pri-
larly categorized and include: attitudinal; legislative; mary care level. These studies and their results will
funding; title; skill limitation; liability; and practice serve as the design templates and research bench-
model limitations. Although it is beyond the scope of marks respectively, necessary for the development of
this review to describe each of these in detail, issues such a comprehensive research program.
identified in common categories include the need to
legitimize the role with standardizations for practice Competing interests: None declared.
and the need to expand the prescriptive authority
and scope of practice. Funding issues include provi- References
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