NP vs. PA • BY ANNE, CCPA & CLAUDIA NP-PHC

Nurse Practitioner vs. Physician Assistant – Scope of Practice, Autonomy & Regulation (Part 2 of 4)

Nurse Practitioner vs Physician Assistant - Scope of Practice, Autonomy and Regulation (1)

Welcome to Part 2 of our series on comparing Nurse Practitioners (NP) to Physician Assistants (PA) in Canada, with a specific focus of the roles in Ontario.

Last updated February 1, 2019. Written by Anne Dang, Physician Assistant and Claudia Mariano, Nurse Practitioner.

In this Article: 

  1. NP vs. PA – Scope of Practice
  2. NP vs. PA – Where We Work
  3. NP vs. PA – How Much Autonomy? 
  4. NP vs. PA – Regulation

PA vs. NP – Scope of Practice

Physician Assistant Scope of Practice:

  • The PA Scope of Practice is flexible and changes according to the supervising physician they work with, and what practice setting/specialty they work within.
    • For example, a PA working with an Emergency Physician can perform any medical act/procedure/assessment the physician is capable of doing, as long as it falls within that physician’s scope of practice, the PA’s competencies and provincial jurisdictions.[1]. In this example, if the Emergency Physician normally performs lumbar punctures, and the ER MD has established that the PA is capable of performing lumbar punctures, then the PA can do lumbar punctures within that setting.
    • HOWEVER, if that Emergency PA were to switch jobs and work in Family Medicine, and performing lumbar punctures is not within the supervising family physician’s scope of practice, even though the PA has a competency to perform that lumbar puncture, because it is not within their supervising physician’s scope of practice the PA would not be performing lumbar punctures within that setting.
  • PAs practice in delegated medical acts:
    • Conduct patient interviews, histories, physical examinations
    • Formulate and communicate a diagnosis
    • Perform diagnostic and therapeutic procedures (e.g. lumbar punctures, reducing, casting and splinting fractures, injections, biopsies, etc.)
    • Ordering and interpreting investigations including blood work and imaging
    • First assist in surgery
    • Inpatient and ward management
    • Consult or refer to specialists
  • In Ontario – According to this OMA document, PAs should be “permitted to prescribe” medications and write orders as delegated by the supervising physician. These are usually done through medical directives (which is a way for the supervising physician “to incorporate frequently delegated acts that performed competency by the PA, and serve to increase efficiency of patient care and improve patient flow“) or as it falls under the Delegation of Controlled Acts (College of Physicians and Surgeons of Ontario).

[1] Canadian Association of Physician Assistants. (2009) Scope of Practice. Canadian Association of Physician Assistants Scope of Practice and National Competency Profile. Accessed Jan 29, 2019 http://capa-acam.ca/wp-content/uploads/2012/12/NCP_en_sept20092.pdf

Nurse Practitioner Scope of Practice:

  • In Ontario, Nurse Practitioners can independently:
    • Perform history and assessment
    • Formulate and communicate a diagnosis
    • Dispense, sell and compound medications
    • Set and cast fractures & dislocated joints
    • Order & interpret all lab tests
    • Admit, treat and discharge patients from hospitals
    • Order some diagnostic imaging tests
    • Consult and refer directly to specialists[2]
    • Can prescribe all medications including narcotics and controlled substances[3]. NPs must complete education required to prescribed controlled drugs and substances.
    • Can provide medical assistance in dying

[2] College of Nurses of Ontario (CNO). Nurse Practitioners Authority and Restrictions.  Accessed Jan 29, 2019 http://www.cno.org/en/learn-about-standards-guidelines/educational-tools/nurse-practitioners/

[3] Ontario Providing New Prescribing Authority for Nurse Practitioners. (April 19, 2017) Accessed Jan 29, 2019 http://www.health.gov.on.ca/en/news/bulletin/2017/hb_20170419.aspx

PA vs. NP – Where We Work

Physician Assistants graduate as generalists, with supplementary experience depending on where they choose to complete clinical rotations during their 2nd year of clerkship. PAs may choose to work in any field of medicine ranging from family practice to Orthopaedic Surgery.

This includes family medicine, Hospital Medicine, Emergency Medicine, Orthopaedic Surgery, Colorectal Surgery, ICU, CCU, Dermatology, Plastic Surgery, Orthopaedic Surgery, General Surgery, Nephrology, Cardiology, Specialty Clinic, Rehabilitation medicine, Oncology, Paediatrics and Gynecology. In the US, there are some PAs working in highly specialized areas such as Interventional Radiology.

Nurse Practitioners are considered Registered Nurses who are in the extended class with additional education and experience. They must use the title RN(EC) to represent RN in the extended class or Nurse Practitioner (NP) in Ontario. The approved designation will be different in each province.

  • Categories of NP Roles:
    • Primary Health Care Nurse Practitioner (NP-PHC): is the largest extended class where the patient population treats everybody (from cradle to grave) and is the most flexible of all the NP-extended classes. Most NP-PHC’s work in the community and not in hospital settings, though they also work in inpatient units in hospitals and in long term care. You may find some NP-PHCs working in Internal Medicine, Cardiology, and Oncology.
    • Adult Nurse Practitioner (NP-Adult): In NP-Adult, as an NP you work with anyone over the age of 18. Often RNs who choose that route have been established in these adult-population practice settings for quite a long time.
    • Paediatric Nurse Practitioners (NP-Paediatrics): Work exclusively with paediatric patients (infants, children and adolescents). Specific work settings include neonatal care (McMaster has specific training program for this) and general paediatrics (University of Toronto has a specific child program).
    • NP-Anesthesia (NP-A): is the newest regulated NP specialty. Involves care of patients and families through perioperative process. There may be intra-operative component to role, but are not administering anesthesia alone in the OR. Apart from OR, they may work in sedation/anesthesia with airway management diagnostic areas. However, this is not a class offered in Ontario thought it may be different in other provinces. There is a program which NPs can take to specialize in Anesthesia, but this is not a registered class of NPs for CNO.

Nurse Practitioner Emphasis Specialties

NP vs. PA – How much Autonomy?

Physician Assistants work in a collaborative/supervisory relationship with a physician. As a new PA graduate this PA/MD relationship usually involves a little bit more direct supervision. As the PA grows in knowledge, skills base, and judgement, the degree of autonomy increases. PAs work within a model of physician delegation. The supervising physician delegates clinical tasks to a PA (assessment, diagnoses, treatment, procedures, prescriptions, etc.).

Autonomy is based on what is negotiated or agreed upon by the supervising physician and PA.[4] This is outlined in a supervisory agreement, or in Ontario this is outlined in a medical directive.

[5] About PAs https://capa-acam.ca/about-pas/

Nurse Practitioners are independent practitioners and work under their own authority as regulated health care providers.

NPs would require medical directives only for those controlled acts which we are not able to perform on our own. While this is very limited, depending on the practice setting, an NP in Ontario would require a medical directive to order a CT or MRI for example, because this is not currently part of our scope of practice. In other provinces this is part of the NP role though. So the need for medical directive is quite limited.

Once you pass the licensing exam and receive your Nurse Practitioner Designation, you can open up your own practice. Very few NPs open an independent practice, as this requires patients to pay them for their service. In Ontario, Nurse Practitioners do not bill OHIP and are salaried employees. This may be different in other provinces such as BC, but the majority of NPs in Canada are not able to open their own practice the way physicians do.

There are no requirements or parameters around what you do once you graduate. Of course, when you are a novice NP, your knowledge skill and judgement will be more limited. Nurse Practitioners do not require medical directives to function autonomously.

There are no requirements to have a formal relationship with a supervising physician the way PAs do, but NPs often work in teams with physicians anyway – just like in Community Health Centres. So although as Nurse Practitioners you don’t require physician oversight or medical oversight, you are still working with a team and consulting with other team members as required. Most physicians are happy to be consulted by a NP or work with NPs if they needed assistance with a patient.

NPs are also able to open up their own clinics independent of physicians. These are called and are funded by the government.   There are 25 NP-led clinics are in Ontario, serving about 90,000 patients right now. Their budgets quite small compared to funding available to other programs, but the Ontario Government will increase funding and expand the Nurse Practitioner model.

NP vs. PA – Regulation

Physician Assistants are not regulated in Ontario. An application was sent to the Health Professions Regulatory Advisory Council (HPRAC) who performed a jurisdictional review, HPRAC found that the evidence submitted did not meets its risk of harm threshold (Canadian Medical Association document).  PAs are regulated in Manitoba under the College of Physicians and Surgeons of Manitoba.

Nurse Practitioners are regulated under the College of Nurses of Ontario (CNO) in Ontario. NPs have been regulated in Ontario since 1998 with the introduction of the “extended class”. Each province has its own regulatory college for nurses, which all NPs are required to be part of.

FINAL NOTES

This article was a collaboration between Anne and Claudia: 

Anne is a Canadian Certified Physician Assistant working in Orthopaedic Surgery and Physical Medicine and Rehabilitation in Ontario. She is the founder and a writer at canadianpa.ca. She is long time blogger and web graphic designer, and loves to use social media and tech as a medium to promote medical education and the PA Profession.

Claudia Mariano graduated from the University of Toronto in 1986 with her Honours Bachelor of Science in Nursing. After working in medical-surgical nursing and public health nursing, she returned to U of T and obtained her Master of Science in Nursing in 1992.

In 1999 she graduated from the Primary Care Nurse Practitioner Program, also from U of T.  Since that time she has embraced primary care and chronic disease management, working at the East End Community Health Centre in Toronto for 10 years, and for the past 10 years at the West Durham Family Health Team in Pickering. Claudia is a Certified Diabetes Educator and has obtained her certificate in Intensive Smoking Cessation Intervention.  She is also a trainer for the Ottawa Model for Smoking Cessation. Her clinical practice is heavily focused on health promotion and self-management of chronic disease.

Claudia is a Past President of the Nurse Practitioners’ Association of Ontario and current NPAO Board member, past Board member of the Association of Family Health Teams of Ontario, current Adjunct Lecturer at the University of Toronto Lawrence S. Bloomberg Faculty of Nursing, and author/editor of No One Left Behind: How Nurse Practitioners are Changing Canada’s Health Care System’.