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Nurse Practitioners

Page modified April 30, 2010

Questions & Answers for Nurse Practitioners

Updated Jan. 7, 2010


The following document provides answers to some of the most frequently asked questions the College has received about Nurse Practitioners (NPs). The College updates these Questions & Answers regularly.

 

Sections

Top 5 FAQs for NPs

 

Q: Can NPs order the H1N1 vaccine?

A: Yes. NPs can administer the H1N1 vaccine, without medical directives, in accordance with provincial protocols. NPs can also provide either a client-specific order, or a directive, to authorize RNs and RPNs to administer the vaccine.

For further information about H1N1 Influenza, click here.

Q: What is the status of the NP scope of practice review?

A: The Ontario government passed Bill 179 (Regulated Health Professions Law Statute Amendment Act, 2009) on December 15, 2009. The legislation addresses many of the College’s requests for changes related to NP scope of practice.

Although the bill has passed, the changes will not take effect until the College and the Ontario government amend regulations.

For more information, click here.

Q: I’m an NP in an in-patient hospital setting. A client who is about to be discharged needs follow-up care. Do I need a medical directive to initiate a referral to a Community Care Access Centre (CCAC) or to order follow-up care?

A: Although any health care provider can initiate a referral to a CCAC, NPs do not have the authority to diagnose, prescribe and treat in-patients. As an NP working in an in-patient setting, you require a medical directive to order follow-up treatment after the client is discharged from the hospital. This is because the client was a hospital in-patient when the order was created. NPs who work in outpatient settings such as emergency departments or ambulatory clinics are authorized to diagnose, prescribe and treat hospital outpatients. This includes ordering treatments as part of a CCAC referral.

Q: I am an NP with a clinical focus in pain management. Can I use a medical directive to provide opioid medications to clients?

A: No; medical directives cannot be used to provide narcotics. Health Canada, the federal department responsible for administering the Controlled Drugs and Substances Act, does not allow medical directives to be used for drugs such as narcotics (which include opioids) and benzodiazepines. To provide these drugs, you require a client-specific order that a physician has authorized. You will also require a physician’s order to change the dosage or renew a prescription.

The intent of this legislation is to ensure that a physician assesses a client’s situation to determine if the prescription is appropriate, and to ensure that the physician authorizes the prescription. Since a medical directive is used for a group of clients, and its use does not involve a physician’s assessment of the appropriateness of the medication for a specific client’s situation, it does not fulfil the federal legislative requirement.

The College will continue to communicate the need for Health Canada to proceed with regulatory amendments to enable NPs to legally prescribe narcotics and other controlled substances.

The College is also collaborating with other regulatory colleges to inform government about practice issues arising from the federal legislation and promote consistent messages among health care professions.

Q: If I am an NP-Adult, can I still provide health care services to children?

A: One aspect of self-regulation means you are accountable to practise according to your specialty. As an NP registered in the adult specialty, it is expected that most of your clients will be adults. Should you occasionally be asked to provide health care services to a paediatric patient, you must exercise judgment. Are you capable of providing the service? Can you manage the outcomes of the requested intervention? Do you have the appropriate resources available? If not, you may decide to refer the client to another health care provider such as another NP or physician. Providing services to a client outside of the population you typically serve should be the exception, not the rule. If you occasionally provide health care services to paediatric clients, to promote transparency, you should inform the client or parent/guardian that you are an NP-Adult.

 

Section A: Use of Titles

1. I just received my NP Certificate of Registration. How do I sign my name?

On documents you complete often, such as client charts, prescriptions and requisitions, you must sign as either Nurse Practitioner (NP) or Registered Nurse, Extended Class (RN[EC]). You may also add your specialty certificate designation:

  • NP-Adult
  • NP-Paediatrics, or
  • NP-Primary Health Care (NP-PHC).

On other documentation for provincial programs such as death certificates, accessible parking permits, statements of medical exemptions for immunization and assistive devices, you should use RN(EC).

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Section B: NP Registration

2. How do I register as an NP? Do I have to write an exam?

NP registration is available to RNs who successfully complete an approved educational program, pass a registration exam and meet the requirements for evidence of safe practice. Click here for the list of Council-approved exams. The NP Registration Guide has been updated and is available online. Click here to request a specialty certificate application package or contact Customer Service at 416 928-0900 or 1 800 387-5526.

3. What is the “evidence of safe practice” requirement?

Evidence of safe practice is a mandatory registration requirement. It is defined as two years of nursing experience within the last five years. One of those two years must have been in an advanced practice role, in which the applicant was required to use advanced knowledge and decision-making skills in assessment, diagnosis and health care management.

4. Can I obtain more than one specialty certificate? Do I need more than one?

You only need to meet the requirements of one specialty certificate to become registered as an NP.  However, some NPs want to register in more than one specialty because they feel it is important for their practice. As well, employers may require specific specialties. If it is relevant to your practice, you may choose to apply for more than one specialty certificate, but you must meet the registration requirements for that specialty including graduation from an approved program, passing the exam for that specialty, demonstrating evidence of safe practice and maintaining quality assurance requirements. If you have not graduated from an approved program for that specialty, the Registration Committee may consider additional education and experience as being equivalent to an approved program. Contact the College for more information.

5. I recently became registered as an NP and was informed that I am no longer considered an RN. If I am registered as an NP, can I still work in an RN role?

As an NP you are an RN in the Extended Class and you may still work in an RN role. However, you are only allowed to use either the RN(EC) or NP title when identifying yourself to clients and signing documentation. For clarity, you should ensure your clients and other members of the health care team understand the type of health care services they can expect from you. For example, although you are an NP, if you are working in an RN role, you will not be providing services such as diagnosing and prescribing.

While working in an RN role, you are still accountable for applying your nursing knowledge at the NP level. For example: as an NP you have competencies in advanced health assessment and diagnosis, which means that you may identify client issues that an RN may not. If so, you would be expected to report your assessment findings to another provider (for example, a physician) for follow up.

NPs who work in RN roles are encouraged to review their professional accountabilities with their employer to ensure both understand what is expected of them and have appropriate strategies in place for client care.

Resources

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Section C: Educational Requirements

6. What programs has the College’s Council approved for NP registration?

An up-to-date list of approved programs according to specialty is posted here.

7. I did not graduate from a Council-approved education program. What information does the Registration Committee need to assess my education and experience to determine education equivalency?

To initiate the assessment process, you must complete an application package. The Registration Committee’s assessment focuses on the applicant’s demonstration of the Canadian NP core competencies (English French). The College assesses each application individually. As a result, the College may require additional information about programs and practice. This information may include, but not be limited to, nursing course outlines, a job description, curriculum vitae and/or a list of medical directives that the nurse has used. The College uses this information to complete a comprehensive assessment of each applicant. For more information about your application or the application process, contact the Customer Service Centre at 416 928-0900 or 1 800 387-5526.

8. Why doesn’t the College distinguish between a master’s NP and a postbaccalaureate NP?

The College of Nurses of Ontario and other Canadian regulatory bodies assess competencies, not credentials. The Canadian NP core competencies, which are common to the practice of each specialty certificate, are embodied in all of the CNO-approved programs.

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9. What is the latest information about the NP exams?

For the latest information about exams, including fees, dates and locations, click here.

10. The approved exams listed on the College’s website are date-specific. What do these dates mean?

The exams met the Canadian core NP competencies as of the dates posted. Applicants who successfully completed the exam in the year posted on the College’s website or after have met the exam registration requirement.

11. I wrote one of the exams approved by Council prior to the stated date on the website, but maintained my competency with credentialling agencies in other ways (for example, I met continuing education requirements and completed portfolios). Do I still need to write an approved entry exam to obtain an NP specialty certificate in Ontario?

Yes, you will still need to write an approved exam to meet the requirements to obtain an NP specialty certificate in Ontario. The entry exam is a mandatory registration requirement. You cannot fulfil that requirement by meeting continuing competency requirements or quality assurance mechanisms, such as continuing education or completing portfolios.

12. Where can I learn more about the NP registration statistics and exam pass rates?

The NP applicants and exam summaries are posted here.

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Section E: American Nurses Credentialing Center (ANCC) Exam Information

13. Why must Ontario nurses write a U.S. exam?

Currently, there are no Canadian Nurse Practitioner exams for Adult and Paediatric entry-to-practice assessment. The ANCC exams have been used in other Canadian jurisdictions for the past few years and have been assessed to ensure they reflect the Canadian NP core competencies (that is, the same competencies taught in our approved NP education programs). The exams are psychometrically adjusted during the scoring process to ensure that Canadian nurses are not at a disadvantage by writing a U.S. exam. Questions that do not apply to nursing practice in Canada are removed from the exam during the scoring process. In addition, the College of Nurses of Ontario and other Canadian regulators are required to facilitate interprovincial mobility. Taking a national approach to NP exams helps to meet this obligation.

14. If questions are removed in the scoring process, do I only have to answer some of the questions?

No, you should attempt to answer every question. It is not possible to know beforehand which questions will be removed in the scoring process as this is based on Canadian exam writers’ performances on the questions overall.

15. How long are the ANCC NP exams?

Candidates are allowed 3.5 hours to write the ANCC exams.

16. What supports are provided to write the ANCC exams?

Study resources are available through the Canadian Nurses Association’s website, additional information is also available on the ANCC’s website. You are not permitted to bring study aids into the exam room.

17. Is there a pass/fail cut-off or are the ANCC exams bell-curved? What details will I receive about my performance on the exam?

There is a pass/fail cut-off. The cut-off is established by a national exam committee responsible for scoring the exams. The committee includes Canadian NPs working with the guidance of the psychometrician. Candidates who pass will receive a report indicating that they have passed. Candidates who fail will receive additional information about their scores and performance in the major content areas to assist them in future exam preparation.

18. How do I schedule my ANCC exam?

If you are eligible for the exam, the College will send you an exam application form. You must submit this application and pay the exam fee. Then, the ANCC will provide you with the information you need to schedule your exam directly with the Ontario writing centres within the timeframes posted on the College website here. Candidates are advised to schedule their exams as soon as possible and should ask the writing centres about their hours of operation and seating capacities, as they differ at each.

19. Does writing the ANCC exam make me eligible for certification in the U.S.?

No. Canadian candidates who write the ANCC exam at a Canadian centre to apply for registration in Canada are not eligible for certification in the U.S. through the ANCC. Successful completion of the exam solely supports the registration process in Canada. Canadian candidates who have obtained the ANCC certification by writing the exam (in 2002 or later) are considered to have met the College’s exam requirement for NP registration in Ontario. To be eligible for U.S. certification, the candidate must apply to write the exam through the ANCC directly and meet the ANCC’s criteria for certification.

20. What is the process for further “Canadianizing” the ANCC exams?

Exam modifications are subject to future collaboration among Canadian jurisdictions and the Canadian Nurses Association, and negotiations with the ANCC, which owns the exams.

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Section F: Scope of Practice

21. What is the status of the NP scope of practice review?

The Ontario government passed Bill 179 (Regulated Health Professions Law Statute Amendment Act, 2009) on November 30, 2009. The proposed legislation addresses many of the College’s requests for changes related to NP scope of practice.
Although the bill has passed, the changes will not take effect until the College and the Ontario government amend regulations.

For more information, click here.

22. I’m an NP in an in-patient hospital setting. A client who is about to be discharged needs follow-up care. Do I need a medical directive to initiate a referral to a Community Care Access Centre (CCAC) or to order follow-up care?

A: Although any health care provider can initiate a referral to a CCAC, NPs do not have the authority to diagnose, prescribe and treat in-patients. As an NP working in an in-patient setting, you require a medical directive to order follow-up treatment after the client is discharged from the hospital. This is because the client was a hospital in-patient when the order was created. NPs who work in outpatient settings such as emergency departments or ambulatory clinics are authorized to diagnose, prescribe and treat hospital outpatients. This includes ordering treatments as part of a CCAC referral.

23. NPs are authorized to order prostate-specific antigen (PSA) laboratory tests for the purposes of diagnosing and monitoring clients. Can NPs also order PSA tests for screening purposes?

A: Yes. Although PSA screening for asymptomatic men is not recommended, clients sometimes request the tests and NPs can order them. NPs should educate clients about the criteria for PSA testing, and the risks associated with receiving potentially inaccurate test results.

As well, NPs should inform clients that OHIP will pay for PSA testing only for diagnosing clients whose clinical history suggests they are at risk, or for monitoring clients who have been diagnosed with prostate cancer. NPs should advise clients not eligible for OHIP coverage to check their third-party insurance provider policies for coverage requirements.

OHIP eligibility criteria for PSA testing are available here.

24. The drug list specifies the route only when there are restrictions or limitations on the route. Are NPs restricted to prescribing only medications that can be taken PO (by mouth) when the route is not specified?

If a drug listed in regulation has no limitations specified, NPs, providing they have the knowledge, skill and judgment, can choose the route they deem appropriate to treat the client’s conditions. The authority of NPs to initiate a prescription for a drug is limited to treating conditions that they can diagnose and for which they can provide the necessary counselling and ongoing management. NPs should review the College’s Nurse Practitioners practice standard for the College’s expectations regarding accountabilities when prescribing medications.

25. If I am an NP-Adult, can I still provide health care services to children?

One aspect of self-regulation means you are accountable to practise according to your specialty. As an NP registered in the adult specialty, it is expected that most of your clients will be adults. Should you occasionally be asked to provide health care services to a paediatric patient, you must exercise judgment. Are you capable of providing the service? Can you manage the outcomes of the requested intervention? Do you have the appropriate resources available? If not, you may decide to refer the client to another health care provider such as another NP or physician. Providing services to a client outside of the population you typically serve should be the exception, not the rule. If you occasionally provide health care services to paediatric clients, to promote transparency, you should inform the client or parent/guardian that you are an NP-Adult.

26. I work in a hospital. If I become registered as an NP, will I be able to practise without medical directives?

If you work in a hospital in-patient setting, the answer is no. Currently, Reg. 965 under the Public Hospitals Act does not give NPs the authority to diagnose, prescribe for and treat in-patients. However, NPs who work in outpatient settings — such as emergency departments or ambulatory clinics — are authorized to diagnose, prescribe for and treat hospital outpatients. The College has recommended to government changes to Reg. 965 that would permit NPs to practise within their legal scope of practice when providing health services to hospital in-patients. Until further notice, NPs who practise in public hospitals with in-patients must use orders (direct orders and medical directives). See the Federation of Health Regulatory Colleges of Ontario’s An Interprofessional Guide on the Use of Orders, Directives and Delegation for Regulated Health Professionals in Ontario.

27. Under the authority of a medical directive, will NPs be permitted to write prescriptions and order laboratory tests to be filled in a community pharmacy or lab for in-patients who are being discharged from hospital?

Yes, NPs working in in-patient areas can write prescriptions and order lab tests using medical directives from physicians, dentists or midwives, which can be processed in community labs and pharmacies. For tools and templates, see the Federation of Health Regulatory Colleges of Ontario’s An Interprofessional Guide on the Use of Orders, Directives and Delegation for Regulated Health Professionals in Ontario.

28. In reviewing the College’s Nurse Practitioners practice standard, I noticed that NPs are not authorized to write an order for another nurse to perform venipuncture for the purposes of drawing blood. Why not?

Provincial legislation does not permit this activity. The College has recommended to government changes to legislation that would permit nurses to accept orders from an NP to perform venipuncture.

For more information on these legislative changes, click here.

29. Why do NPs require medical directives to perform simple point-of-care laboratory tests such as rapid strep tests and urine dipstick analyses?

A health care practitioner who performs laboratory tests for the purpose of diagnosing or treating patients requires an exemption under Reg. 682 of the Laboratory and Specimen Collection Centre Licensing Act. The College has recommended to government changes to this legislation that would exempt NPs and enable them to perform these tests, which are an essential part of their practice. The government is reviewing the College’s recommendations.

30. Can NPs prescribe opiates?

Currently, NPs do not have the authority to prescribe opiates, including derivatives or synthetic formulations. The Controlled Drugs and Substances Act is federal legislation that governs the practice of prescribing controlled drugs in Canada. In March 2004, Health Canada’s Drug Strategy and Controlled Substances Programme announced plans to begin consultation on potential regulatory amendments under the Controlled Drugs and Substances Act that would expand prescriptive authority to other health professions, including NPs. The College has provided feedback on the proposed federal regulations that would permit NPs to prescribe controlled substances.

31. I am an NP with a clinical focus in pain management. Can I use a medical directive to provide opioid medications to clients?

No; medical directives cannot be used to provide narcotics. Health Canada, the federal department responsible for administering the Controlled Drugs and Substances Act, does not allow medical directives to be used for drugs such as narcotics (which include opioids) and benzodiazepines. To provide these drugs, you require a client-specific order that a physician has authorized. You will also require a physician’s order to change the dosage or renew a prescription.

The intent of this legislation is to ensure that a physician assesses a client’s situation to determine if the prescription is appropriate, and to ensure that the physician authorizes the prescription. Since a medical directive is used for a group of clients, and its use does not involve a physician’s assessment of the appropriateness of the medication for a specific client’s situation, it does not fulfil the federal legislative requirement.

The College will continue to communicate the need for Health Canada to proceed with regulatory amendments to enable NPs to legally prescribe narcotics and other controlled substances.

The College is also collaborating with other regulatory colleges to inform government about practice issues arising from the federal legislation and promote consistent messages among health care professions.

32. Can NPs order the H1N1 vaccine?

A: Yes. NPs can administer the H1N1 vaccine, without medical directives, in accordance with provincial protocols. NPs can also provide either a client-specific order, or a directive, to authorize RNs and RPNs to administer the vaccine.

For further information about H1N1 Influenza, click here.

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Section G: Quality Assurance

33. What are the NP’s current Quality Assurance Program obligations?

For information on the College’s QA Program, click here.

 

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