Reflections of a Nurse Practitioner: Q&A with Claudia (Part 4 of 4)

Reflections of a Nurse Practitioner Q and A with Claudia

Welcome to Part 4 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.

Q. How do you explain the difference between an MD and NP?

I tell patients now that it is easier to discern MD vs. NP by what we cannot do – which will vary by jurisdiction. In Ontario, we cannot order CT/MRI. Though that legislation was passed over 10 years ago it still has not been proclaimed.

Scope of practice and degree of autonomy also depends on the knowledge skill and judgement of the individual nurse practitioner, just as with any professional.

Physicians have a broader and deeper experience and education related to illness and diagnoses, which is absolutely needed. Just as family physicians refer to specialists, when the family doctor has gone beyond their knowledge and skill, nurse practitioner will refer to their knowledge skill and judgement. It will certainly depend on the nurse practitioner.

NPs work in palliative care and end of life care, in addictions and mental health, and may have more comfort prescribing many medications for pain management, than some physicians have, because that was their area and knowledge.

Q. How is the Role Different from an RN? from an RPN?

Scope of Practice is determined by each province.

More taking care of patients, including patients who aren’t quite stable. The RN position includes responsibilities that may require critical thinking RPNs deal with patients who are stable, who have predictable and expected health care needs related to whatever their condition
University Level Education – Degree College Level Education – Diploma

Q. What do you find challenging about being an NP?

There are some limitations, as Nurse Practitioner are employees. In primary care, you are hired as an NP-PHC in CHC, FHT or employed by a hospital. We’re still employees, and expected to function in a certain way, and an employer may not allow us to work to the full scope of practice as a nurse practitioner. Working with an NP can make the physician’s life easier, and can help a physician make some more money. However, in this scenario the NP may not be necessarily practicing to the top of their scope of practice. That can still be constrained.

In a NP-led clinic everyone is working to full scope of practice. This can be the case also if there is NP role clarity in other settings.

Q. What steps should an MD take if they are interested in working with a Nurse Practitioner?

It is not as common for MDs to work directly with NPs because in this instance the MD would have to pay the NP out of pocket. It does happen, and physician can take more time off and take on new patients, and more comprehensive services. There are other benefits, and quite a few Nurse Practitioners who choose this route.

Q. RNs are obtaining prescription rights in Ontario – does the blur the line between the NP and RN role when it comes to role clarity?

I don’t think so, it’ll be quite specific. There will likely be certain instances that those prescriptive rights are allowed. For example, RNs administer immunizations all the time, and there should be no reason that RNs can’t prescribe immunizations. It is up to CNO to put specific regulations in place that will clarify when RNs are able to prescribe.

Years as ago when I was working in a sexual health clinic as an RN, there was no reason I wouldn’t have the knowledge to prescribe antibiotics for the STDs since I was able to diagnose and manage these conditions – but as an RN I did not have the scope of practice to do so. Extending these prescriptive rights would be appropriate in examples such as these to help expand access for patients in rural and remote areas.

Q. What are differences between Canadian and American Nurse Practitioners?

In America, how Nurse Practitioners are utilized differs between each state, just as in Canada Nurse Practitioner utilization differs by each province and territory. Funding for Nurse Practitioners is different in the US because they do not have universal health care model. There are many states where NPs are fighting for prescriptive authority, and for many of the authorities that Nurse Practitioners have here.

Q. Can Nurse Practitioners cross Provinces?

Because health care is the provincial initiative, in every province you must be registered by that regulatory body. This process involves showing the NP regulatory body proof of your education to ensure there are no restrictions on your license. . This does not involve re-writing any kind of licensing exam, as your NP license is portable between provinces and territories

Q. Is there an adversarial relationship between Nurses and Physician Assistants?

I’ve always believed there is more than enough work to go around – especially when it comes to patient care. There is a role for Physician Assistants, Physicians and Nurse Practitioners to treat patients.

Health care providers can get stuck feeling threatened by other health care providers. But if we understand that every health care provider is a legitimate provider with a skillset, education, knowledge and ability to improve health care – patients can benefit.

Funding models are the biggest barriers, and it really impacts health care – this is where the balance of power resides.

Regardless of the title, let’s have people work to the top of their scope of their practice. We don’t need to be fighting over it – we all have our particular area of expertise, and we’re all working towards the same goal of treating patients – we should not start throwing each other [health care providers] under the bus.

Q. How did the Nurse Practitioner profession successfully integrate itself into Canadian Health Care system? Especially since it was a new and innovative role at the time!

There is a LOT of data that points to strong outcomes, and great patient outcomes. As annoying as it was to have to consistently prove our value, we have solid research that show NP involvement improves care.

Patients were also really happy the care that they received from Nurse Practitioners. Feedback from patients was extremely positive. Patients feel they are getting good care and that does change the conversation.

I published a book a few years ago highlighting the NP role in different settings across Canada. The role started when the NDP government of the day decided to open the NP program again in the 80s, because the health minister, Ruth Grier, was so impressed with the care she received at a CHC, and she felt this should be an option for more people. I talk about this a bit in the book –

Q. How did you get that body of evidence to prove the value of Nurse Practitioners? 

The body of evidence to prove the value of Nurse Practitioners comes from science-based research organizations. Some studies were government funded because they wanted to look at different models of care, some of these came from Canadian Institute for Health Information (CIHI), and some from the American studies on utilization and value of Nurse Practitioners. A lot of the research initially came from US studies as they have been utilizing NPs for a long period of time.

Health Quality Ontario has an annual report every year, and there are items in the annual report about nurse practitioners. Patients do fare better when working with a nurse practitioner

Q. Are nurses unionized? And therefore Nurse Practitioners unionized?

If a nurse is hired through a hospital, they are likely unionized (Ontario Nurses Association – ONA). I’ve never practiced as part of a union and as most of my career has been in primary health care and Public health units.

NPs who are hospital employees are likely unionized as well.

There are no restrictions on NP practice and any “restrictions” (e.g. hours worked) purely depends on what is negotiated individually. There has NEVER been a stipulation for maximum number of patients seen in a day by a Nurse Practitioner.

If a nurse is part of a managerial role, then they are likely not unionized.


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 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’.