About Nurse Practitioners
Nurse Practitioner History in Ontario
Nurse Practitioners (NPs) are registered nurses with an expanded legislated scope of practice. NPs deliver nursing care at an advanced level to specific patient populations in a variety of health care settings. All NPs in Ontario are now registered in the Extended Class with the College of Nurses of Ontario as one of four NP specialities: NP-Primary Health Care, NP-Adult, NP-Pediatric or NP-Anesthesia. Within each of these broad areas of specialization, NP practice may be broad or narrow in focus depending upon the needs of the patient population in specific practice settings coupled with the knowledge and experience of the NP.
The foundation for NP practice is that of a registered nurse with general class registration with the College of Nurses of Ontario. Additional education, experience and registration in the extended class with the College of Nurses of Ontario enable NPs to practice with a broader scope of practice. With this additional scope of practice, NPs integrate the controlled acts of communicating medical diagnoses, ordering diagnostic tests, and prescribing medications and treatments to their nursing practice. This additional regulated authority represents nursing’s full scope of practice. NPs work both autonomously and collaboratively with physicians (both family physicians and specialists), registered nurses and other health care professionals in delivering health care in a variety of health care settings.
The Expanded Nursing Services for Patients Act was proclaimed in 1998 following 25 years of lobbying. This marked the beginning of a formal process enabling nurses to be registered with the College of Nurses in a new “Extended Class” encompassing additional authority to perform controlled acts and other aspects of practice not authorized to nurses registered in the general class. The complexity of health care legislation necessitates ongoing consultation, collaboration and support from many groups in a variety of settings to remove the remaining barriers to NP practice to achieve full integration of NPs in Ontario’s health care system.
Historical Perspective
NPs have been working in Ontario since the early 1970s. The role was first developed to expand the scope of practice of RNs working in northern and under-serviced communities where access to health care services was lacking. University programs were established and focused on the NP role in primary health care settings. These programs closed in 1983 as a result of lack of both funding for positions and legislative support for the role. Despite these barriers, approximately 250 NPs continued to work in Ontario throughout the 1980s and early 1990s. Beginning in 1994, many of these NPs were instrumental in creating new initiatives with the Ministry of Health and Long Term Care as part of government’s primary health care reform strategy. This resulted in the re-establishment of NP university education programs in 1995 and the Expanded Nursing Services for Patients Act which was passed in 1998. This legislation gave NPs registered in the extended class with the College of Nurses of Ontario (initially primary health care NPs) the authority to practice within a broader scope of practice which included three additional controlled acts: communicating a diagnosis, prescribing a limited range of drugs, and ordering certain tests, x-rays and ultrasound.
Nurse Practitioners working in acute care were first titled Expanded Role Nurses in several Ontario hospitals in the mid-1980s. Other titles such as CNS/NP (Clinical Nurse Specialist/ Nurse Practitioner), APN (Advanced Practice Nurse) and ACNP (Acute Care NP) were also used for these evolving roles. Many of these initial NPs practicing in hospital settings were established Clinical Nurse Specialists with masters level nursing education and experience in a specialty area prior to pursuing post graduate nurse practitioner education. Initially, these roles were not regulated under the Expanded Nursing Services for Patients Act and were enabled with the use of physician approved medical directives and protocols. Education programs since 1994 at the University of Toronto, McMaster University and for a short period at the University of Western Ontario helped to promote the role and to prepare RNs for this expanded role.
Today there are over 400 NPs working in inpatient and/or ambulatory hospital settings in a wide range of specialties such as oncology, cardiology, general and specialty surgery, neurology, neonatology, palliative care, seniors health, pain management and critical care. These NPs practice in community, tertiary and quadruciary care centres. In August 2008, the title “Nurse Practitioner” became protected and the process for registering NPs not currently registered in the extended class began. Work is ongoing to fully enable the NP role in the inpatient hospital setting. In October 2003, the College of Nurses of Ontario issued a paper entitled “Acute Care/Specialty Nurse Practitioner: Policy Issues Relevant to Regulation of the Role” which identifies some of the key considerations for including NPs working in hospital settings to be included in the extended class category. Extensive consultation including presentations and written submissions with the Health Professions Regulatory Advisory Council (Extended Class Nurses, Drug Regulation for Nursing, Interprofessional Collaboration), Bill 179 and most recently the Public Hospitals Act represent some of the recent and ongoing efforts to further influence policy to enable NPs from all specialties to practice to their full scope of practice.
Four Regulated NP Specialties in the Extended Class:
NP-PHC; NP-Adult; NP-Pediatric; NP Anesthesia
NPs in all four specialties may practice in a variety of settings. The health care needs of the patient population and the needs of the health care team are matched with the competencies and experience of the NP impact where individual NPs practice.
NP: PHC (Primary Health Care)
Primary Health Care Nurse Practitioners are registered nurses (RNs) who are specialists in primary health care and provide accessible, comprehensive and effective care to clients of all ages. They are experienced nurses with additional nursing education which enables them to provide individuals, families, groups and communities with health services in health promotion, disease and injury prevention, cure, rehabilitation and support. NPs-PHC establish collaborative relationships with physicians and most often work as part of interprofessional teams in a variety of health care settings. The NP’s knowledge and skills include the ability to:
- Provide wellness care such as monitoring infant growth and development and health screening activities such as Pap smears;
- Provide counselling and treatments to assist individuals with lifestyle decisions, such as smoking cessation and weight loss;
- Diagnose and treat minor illnesses, such as ear infections and contact dermatitis;
- Diagnose and treat minor injuries, such as sprains and lacerations;
- Manage women during and after pregnancy;
- Manage individuals with stable chronic diseases, such as diabetes, hypertension and a variety of respiratory conditions.
Evolution of the NP-Adult; NP-Pediatric; NP-Anesthesia specialties
Nurse Practitioners with adult and pediatric specialty designations are members of a health care team who provide health care services to a wide range of patient populations, addressing the health and wellness care for individuals and families with acute and chronic conditions in a variety of settings including hospitals (inpatient and ambulatory areas) as well as community settings. These NPs anticipate, analyze, diagnose, communicate, intervene and evaluate both the usual and the unpredictable elements of human responses to acute and chronic illness. Additionally, these NPs provide professional practice leadership in health care settings by participating on and leading teams through initiatives that strive to enhance both the access and quality of health care services. Domains of practice associated with these NP roles include: clinical practice, education, research, professional leadership and management of change/program development. Within these competencies the NP’s knowledge and skills include:
- Diagnosis, treatment and ongoing support for patients and families living with an array of acute and chronic complex conditions such as acute coronary syndrome, congestive heart failure, sepsis, asthma, COPD and pain
- Ongoing management and support for patients and families with life threatening disease such as cancer, and those awating organ transplantation
- Implementation of research-based practice
- Evaluation of outcomes of a patient-centered program
- Preceptor for other health care providers, especially other nurses.
The NP-Anesthesia role (NP-A) is the newest evolving regulated NP specialty. This role incorporates care of patients and families throughout the perioperative process including preoperative assessment and preparation, intraoperative and post operative care. There may be an intra‐operative component to the role but NP‐A is not a sole provider of anesthesia. The NP-A may work on or lead an acute pain team with anesthesia colleagues. Additionally the NP-A may work in diagnostic areas where patients require sedation/anesthesia with airway management.
Nurse Practitioners’ Association of Ontario
The Nurse Practitioners’ Association of Ontario (NPAO) was founded in 1973 and is an Interest Group of the Registered Nurses Association of Ontario. NPAO was founded to represent NPs working in primary health care settings, but expanded its mandate in 1998 to include NPs working in all settings.
NPAO provides its members with professional support and educational opportunities. As the voice of NPs in Ontario, the Association continues to lobby for integration and policy to support integration of NPs into our health system as well as for the critical health issues that affect the well-being of individuals, families and communities. NPAO maintains a strong commitment to the profession of nursing in Ontario .
NPAO is governed by a voluntary Executive elected by the membership. NPAO jointly sponsors an annual conference, maintains a website, publishes a newsletter and offers awards bursaries. Members of NPAO represent the organization on task forces and committees in their local communities and at both the provincial and federal levels.
