May 2016

Working with physician assistants

We often get questions from nurses seeking to understand their accountabilities when working with physician assistants (PAs). The following are answers to the most common questions we get.

Who are PAs?
PAs work in a range of health care settings, under the direction of a physician. The role depends on the PA’s competencies, the supervising physician’s area of practice and the duties the supervising physician assigns. Examples include conducting client interviews and taking medical histories, performing physical exams, performing certain controlled acts as delegated by a physician and providing counselling on preventive health care.

Are PAs regulated?
PAs are unregulated care providers (UCPs) and are not accountable to a regulatory body.

Can I accept orders from a PA to perform a controlled act?
No. Under the Nursing Act, 1991 nurses can only accept orders for controlled acts from the following regulated health care professionals: physicians, nurse practitioners, chiropodists, dentists and midwives.

Can I accept orders from a PA to perform a procedure that is not a controlled act?
If the procedure is not a controlled act, then whether you accept the order depends on the legislation that is relevant to your setting and your organization’s policies. For instance, under provincial legislation, PAs cannot authorize orders in hospitals or long-term care homes. You should check your organization’s policy about who can order a procedure that is not a controlled act. As always, you should use your judgment and ensure your practice is consistent with College standards.

If a PA implements a medical directive involving a nurse, is the nurse accepting an order from a PA?
No. The medical directive is a physician’s order. If a PA initially implements a medical directive that authorizes the PA and a nurse to perform a procedure, the nurse is not viewed as accepting an order from the PA. If you find yourself in such a situation, you should follow the same steps you would if the PA were not involved. For example, you should ensure that specific client conditions have been met.

In some circumstances, a PA may transcribe an order in a client’s chart based on a medical directive. If this order includes something a nurse will be doing (for instance, performing venipuncture or administering medication), then the nurse is considered to be “co-implementing” a medical directive with the PA.

What are nurses’ accountabilities when implementing a medical directive with a PA?
Before implementing medical directives, nurses should be involved in the development and approval of the directives — if not directly, then through an appropriate nursing representative. Nurses who implement directives must understand how they will be applied in their practice setting. They should apply their own knowledge, skill and judgment to determine if it is appropriate to implement the directive.

Do I require delegation when implementing a medical directive with a PA?
You require delegation when performing a controlled act that is not authorized to nursing under the Nursing Act, 1991. The delegation must come from a regulated health care professional who is authorized by legislation to perform the controlled act (for example, a physician). A physician can delegate a controlled act to a PA, giving them the authority to perform the controlled act. However, the PA cannot then delegate the controlled act to a nurse.

Can I accept verbal orders communicated through a PA?
No. The only time you can accept verbal orders is when the prescriber (in this case, a physician) is unable to document the order. However, if organizational policy supports it, a PA can transcribe a verbal order from a physician into the client’s chart. If you have questions about the order, then you should verify it with the prescriber.

Where can I learn more?
For specific information on the PA role, visit and search for “physician assistant.”

To learn more about nurses’ accountabilities while working with unregulated care providers such as PAs, refer to the following resources:

Working with Unregulated Care Providers
Authorizing Mechanisms
Controlled Acts Webcasts
Federal Health Regulatory Colleges of Ontario – Guide to Medical Directives and Delegation

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