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In order to proceed with regulatory recognition of the Acute Care/Specialty Nurse Practitioner (AC/SNP), there are outstanding issues that need to be resolved - issues such as clarification of terminology, minimum educational requirement, title protection, and placement within the existing regulatory framework.
The College of Nurses of Ontario (CNO) has previously struggled to come to grips with nursing role terminology, especially with the concept of advanced practice nursing. To date, CNO has avoided the use of the term "advanced practice", classifying it as professional language, and has relied instead on the regulatory concept of "extended class" to describe the extended practice role of the Primary Health Care Nurse Practitioner (PHCNP). This avoidance of terminology has made it difficult at times to communicate clearly with members of the general public, consumers of health care, other health care providers, and with our own members, as to the depth and breadth of emerging roles such as the PHCNP and the Acute Care/Specialty Nurse Practitioner (AC/SNP).
In addition to avoidance of the term advanced practice, CNO has paid scant attention to the concept of specialty practice e.g. wound care nursing, critical care nursing, rehabilitation nursing. Regulatory efforts have focused on the entry competencies and core strengths of the generalist nurse and extended class nurse, assigning specialty content and quality to the realm of a voluntary, professional certification process. The lack of definition of specialty practice has also left a void in the appropriate placement of members such as Clinical Nurse Specialists, administrators, educators and researchers within the current regulatory framework. Our current approach to specialty practice raises significant questions surrounding the scope of regulation of AC/SNPs in terms of the regulation of core nurse practitioner competencies possessed by every nurse practitioner regardless of area of practice, versus specialty competencies unique to individual acute care/specialty nurse practitioners.
To date, CNO has relied on its regulatory language of extended class rather than the more commonly used term of Nurse Practitioner. CNO's intent at the time of its conception of extended class was to be visionary and allow for the evolution of additional "extended nursing roles". Extended class has been and still is meaningful and visionary language for a regulator, but it is of little significance to the public, and has made it difficult for the public to grasp the purpose and scope of the nurse practitioner role. It is timely for CNO to consider title protection of nurse practitioner, a term that is commonly used within the health care system, and that has meaning to consumers and to the general public. There is currently support within the profession, and within the nurse practitioner group itself for movement to title protection.
CNO has also grappled with the minimum education level expected of its practitioners. Historically, there has been a lack of consensus amongst academics, professional associations, members of the profession, and regulatory bodies regarding the minimum level of education to qualify for advanced practice status. A decision is required as to the minimum education expectation, prior to the incorporation of the AC/SNPs into the extended class.
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After conducting an extensive literature review of past and current attempts to define Advanced Practice Nursing (APN), the following composite1 is offered as the definition that best captures the current and anticipated APN roles here in Ontario.
Advanced practice nursing (the advanced practice of nursing) is a global term used to describe the entire spectrum of advanced practice in which nurses apply maximum nursing knowledge and skill to meet the needs of clients. Their knowledge and skills represent an integration of information from the multiple domains of clinical practice, research, education, collaboration, change agency and leadership.
Advanced practice may be focused solely within the scope of nursing practice, or it may extend to incorporate, with appropriate authorization, activities that fall within the traditional scope of medical practice, including functions such as diagnosing and prescribing as well as specific procedures or technical skills. APN includes roles such as the Clinical Nurse Specialist, Primary Health Care Nurse Practitioner, Acute Care/Specialty Nurse Practitioner, and will include other extended roles e.g. Nurse Anaesthetists, as they emerge.
Figure 1: Advanced Practice of Nursing
Much work has also been done by many nursing organizations, to identify the
key
characteristics of advanced practice. In the late 1990's CNO, along with regulators
from other Canadian jurisdictions, participated in a national working group
led by the Canadian Nurses Association (CNA) and came up with the following
characteristics to describe advanced practice nursing:
* The following characteristic was added by Council during its policy discussion
at October
Council:
The proposed definition is global, encompassing nurses practising at an advanced level who require additional regulation because of their extended scope of practice e.g. Nurse Practitioners, and nurses practising at an advanced level strictly within the traditional nursing scope e.g. Clinical Nurse Specialists. The definition includes the concept of a maximum application of nursing knowledge and skill to meet client need, which is in keeping with CNA's definition in its document Advanced Nursing Practice: A National Framework. The definition also includes the integration of knowledge from multiple domains of nursing practice originating with the core graduate level competencies of clinical practice, research, education, collaboration, change agency and leadership. These graduate competencies, integral to an expert level of practice that contributes to the meeting of client needs, and to the continuous growth of the nursing profession, are also referenced in CNA's framework document.
The key characteristics describe the application of graduate competencies to nursing practice, and emphasize the integration of nursing knowledge with knowledge from other disciplines. They emphasize the concepts of critical analysis, autonomy of practice, application of both theory and evidence-based knowledge to practice, and to influencing the development and/or direction of health policy.
A descriptor of advanced practice is in keeping with the intent of labour mobility and reduction of barriers to practice. Fifty of the American nursing boards have language that addresses the advanced practice of nursing and the National Council of State Boards of Nursing has adopted a nurse licensure compact for advanced practice registered nurses, similar to its compact for RNs and LPNs. States that pursue regulatory approval of the compact can allow advanced practice registered nurses who are licensed in any state of the compact to practice in their state. This is comparable to the Canadian concept of mutual recognition agreements. Movement to adopt advanced practice terminology prepares CNO for potential opportunities for future jurisdictional collaboration, both within Canada and internationally.
If a descriptor of advanced practice of nursing is not accepted, CNO can continue with the current status quo, but will have to rely increasingly on its regulatory language of extended class for a portion of its practitioners who are working at a highly complex level of practice, and will continue to have no way of fully capturing the practice of many of its members, such as Clinical Nurse Specialists, who practice at a non-extended, complex level. This hinders communication with the public in general, and with all levels of stakeholders both within Ontario and without.
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A specialty nursing role may be clinical, or it may refer to a specific dimension of practice other than direct care such as administration, education or research.
CNA describes specialized practice as concentrating on a particular aspect
of clinical nursing and states that the focus of practice may be related to
age (paediatrics, gerontology), a specific issue (pain management, bereavement),
a medical diagnostic grouping (orthopaedics, cardiology), practice setting (emergency
department, home care), or the type of care (wound care, critical care, palliative
care).
The American Nurses Association (ANA) offers a definition of specialty nursing
that covers not just the practitioners of clinical care, but also the roles
of administrators, researchers and educators. ANA suggests that specialty nursing
is "nursing practice that intersects with another body of knowledge, has
a direct impact on nursing practice, and is supportive of the direct care rendered
to patients by other nurses."
The following composite definition covers the spectrum of specialty practice roles:
Specialty practice may focus on a specific area of nursing and be categorized by age (paediatrics, gerontology), a specific client care issue (pain management, bereavement), a medical diagnostic grouping (orthopaedics, cardiology), practice setting (emergency department, home care), or the type of care (wound care, critical care, palliative care). Specialty practice may also refer to nursing practice that intersects with another body of knowledge that has a direct impact on clinical nursing practice, and is supportive of the direct care delivered to clients by other nurses.
Specialty practice encompasses clinical specialties, administration, nursing education and research.
Specialty knowledge and expertise is gained through experiential learning and through educational credentialing. To date, given that the practitioners of specialty nursing function within the traditional nursing scope of practice and do not require access to an extended scope of practice, they have not required additional regulation of their entry to practice to protect the public.
It is important that CNO recognize a definition of specialty practice that accommodates all of its members, both RNs and RPNs, who are practising within focused areas of nursing. It is also important to be able to distinguish the specialty practitioner from the advanced practice nurse. The specialty practice nurse has not required additional regulation beyond the general class entry to practice requirements, and has relied on voluntary professional certification and compliance with CNO's quality assurance to address ongoing competence .
This reliance on professional certification and quality assurance becomes a critical decision point when considering the regulatory safeguards that should be applied to the AC/SNP role. If CNO recognizes specialty practice amongst its members, both clinical specialty and dimension specialty, and is satisfied with its public protection role with respect to current specialty practice, then it is logical to maintain a consistent approach with the "specialty" aspect of the AC/SNP role.
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The required level of educational preparation for nurses has always been controversial. The issue of movement to baccalaureate level from diploma level for Registered Nurses was the subject of considerable debate over many years, and even yet remains controversial for some stakeholders. The movement from secondary school preparation and a community college certificate for Registered Practical Nurses has only recently been addressed, and the change is still in progress. The determination of the minimum level of education required for advanced practice nurse has been equally controversial, and only recently has there been consensus amongst some of the Canadian nursing groups as to the master's level requirement.
CNA, in revisions to its Advanced Nursing Practice: A National Framework, has specified that the minimal educational requirement for advanced practice nursing is a graduate degree in nursing. The Canadian Association of Advanced Practice Nurses (CAAPN) states that "given the independence of the role, the collegial relationship expectations with other health care providers (in particular physicians) whose entry to practice is at the graduate level, it is essential that advanced practice nurses (APNs) be prepared at the graduate level as well." The Clinical Nurse Specialist Interest Group includes its educational requirement of graduate preparation in nursing within its definition of the Clinical Nurse Specialist (CNS). The current Ontario Acute Care/Specialty Nurse Practitioner educational programs are at the master's and post master's level.
The International Council of Nurses (ICN) recommends a master's degree, and the American Nurses Association requires a masters or doctorate nursing degree for recognition as an advanced practice nurse,
The other major Canadian organizations associated with the advanced practice of nursing e.g. Canadian Nurses Association, Canadian Association of Advanced Practice Nurses have recognized the need for an advanced level of preparation in nursing in order for the APN to safely and effectively carry out the responsibilities of the advanced practice role. This is no longer a proactive decision, but a decision based on already identified needs from the practice settings and by the practitioners themselves. (For information on educational requirements in other Canadian jurisdictions, see Attachment 2).
Currently, the PHCNP educational program is at the baccalaureate and post baccalaureate level. This has drawn some criticism and comment from other health care practitioners, especially physicians, who are reluctant to be supportive of the role, given what they see as limited educational preparation. However, 16% of the RNs who are registered in the extended class as PHCNPs already have a master's credential, in addition to their Nurse Practitioner educational program - 10.2% in nursing, and 5.4% in non-nursing, and 2 individuals have doctorates, one in nursing and one non-nursing2.
All of the current AC/SNP programs are offered at the masters or post masters level, and all CNSs in accordance with their professional association (the Clinical Nurse Specialist Interest Group) and by CNA's position statement must have a masters degree or doctorate in nursing with expertise in a clinical nursing specialty. There would have to be a grandparenting accommodation however, for currently practising AC/SNPs who graduated from early programs with a non-nursing master's degree.
There is also a public safety expectation related to educational preparation that implies that nurses prepared at the graduate level are capable of functioning at an advanced level of practice because of their greater ability to develop abstract and critical thinking, to carry out advanced assessments, and to integrate a broad spectrum of knowledge into the selection of therapeutic options for client care.
There may be some argument that the minimum requirement of a master's in nursing should also cover nurses practising in a dimension specialty e.g. administration, education, research. However, the other dimensions of nursing, given the suggested advanced practice definition and characteristics, more appropriately belong under the specialty practice classification than under the advanced practice of nursing classification. Practitioners in these dimensions may have masters or other advanced preparation, but often their preparation maybe in a discipline related to their specialty e.g. Masters in Business, Masters in Health Administration, Masters in Education, Masters in Research and Design. This educational preparation is appropriate to their roles.
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In 1994, in written communication to CNO regarding the regulations to implement
the PHCNP role, the Health Minister of the time, Ruth Grier, stated that the
Ministry fully supported the need for title protection for Nurse Practitioner.
However, CNO Council chose not to opt for title protection for the Nurse Practitioner
role at the time that the extended class regulations were developed, wanting
to see what happened at the national level with the Nurse Practitioner role
and title in other provinces.
Currently, New Brunswick, Nova Scotia, Newfoundland & Labrador and the Northwest
Territories have title protection for Nurse Practitioner (see Attachment 1).
The Registered Nurses Association of British Columbia (RNABC) has recommended
title protection to its provincial government, Quebec is considering the possibility
of asking for legislative amendments for title protection, and Prince Edward
Island has identified title protection as a priority when its Nurse Practitioner
legislation is introduced.
The most important reason for moving to title protection is to protect the public from unqualified practitioners who inappropriately refer to themselves as something that by education, experience and competence they are not. With title protection of Nurse Practitioner, only members who have met the minimum educational requirements and who have completed satisfactorily the specific entry to practice examination for RNs in the Extended Class would be able to refer to themselves by the title Nurse Practitioner. This would facilitate communication with the public and other stakeholders as to the Nurse Practitioner role and the qualifications of those practising in the role.
A secondary reason is to establish parity of terms with many of the other Canadian provinces who have already moved to legislative protection of the title Nurse Practitioner. Parity of terms such as Nurse Practitioner and advanced and specialty practice may facilitate labour mobility issues that arise out of Canada's internal trade agreement (AIT).
The issue of title protection is critical to our efforts to communicate nursing roles to the public, especially as we move to increase the number of practitioners who are regulated within the nurse practitioner role.
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The current regulatory model is based on two major classes - general and extended4. Currently, the only members in the extended class are the PHCNPs. All other RNs and all RPNs are members of the general class. This currently includes the Clinical Nurse Specialist, who is an advanced practice nurse, nursing administrators, educators and researchers, who are specialty practice nurses, and RNs and RPNs who are clinical specialty nurses. None of the roles within the general class require access to extended practice authority.
The Nursing Act is written in such a way that other registered nurse roles seeking legislative authority to perform additional controlled acts may be added to the extended class e.g. AC/SNPs, nurse anaesthetists.
In Ontario, each regulated health profession has a scope of practice statement in its profession specific act that describes the boundaries of practice within which its members carry out their responsibilities. The nursing scope of practice statement5 in the Nursing Act provides the context for the performance of the three controlled acts authorized to members of the profession. The controlled acts and the scope statement together, define a scope of practice common to all members of the nursing profession, regardless of class or category.
RN (EC)s are authorized to perform an additional three controlled acts6. This gives them, in regulatory terms, an "extended scope of nursing practice". This extended scope of practice forms the basis for a dynamic regulatory model that can grow to accommodate the new extended nursing roles as they develop.
To date, CNO has identified entry to practice competencies for RNs and RPNs, and PHCNPs, and ongoing competencies that form the basis of the written component of Practice Review. While not formally recognized by CNO, the core competencies of clinical practice, research, leadership, collaboration and change agency have been identified by academics as a component of graduate preparation in nursing, and have been identified as consistently evident characteristics of advanced practice nursing by CNA.
Work is currently underway at the national level to identify core nurse practitioner competencies. Depending upon the outcome of the national effort, CNO may or may not need to work independently on identifying the core competencies required for the AC/SNP role.
CNO is responsible for assessing competency for the practice of nursing at the entry level, and for working to assure a level of continuing competency amongst the membership. The focus of assessment is on adherence to professional standards, general and specific practice expectations, and legislation and regulations. An ability to meet these standards is interpreted as an ability to provide safe, effective and ethical care. The assessment methods (registration and quality assurance) address nursing in general. They do not cover specialty areas of practice.
Verification of competency in a specialty area of practice for the general class of RN has been accomplished either through a formal education program leading to credentialing e.g. the Clinical Nurse Specialist and a masters degree, or through professional certification e.g. the RN certified as a specialist in a specific area of practice by means of the Canadian Nurses Association's professional certification program.7
To date, for RPNs there is no formal certification process at the professional level for specialty areas of practice. However, many of the community colleges, both in Ontario and in other Canadian provinces have developed educational programs for targeted areas of practice e.g. community nursing, gerontology, Operating Room nursing. There are several specialty interest groups in place that are affiliated with the RPNs professional association, the Registered Practical Nurses Association of Ontario (RPNAO) - groups such as the Operating Room Specialty Interest Group, Independent Business and the Occupational Health Nurse.
A decision is required with respect to CNO's role in assessing specialty competence for the AC/SNP role. Some potential options are to 1) remain consistent with current processes and leave the specialty area of practice to a professional certification process and to the academic credentialing process 2) develop specialty registration exams for each clinical specialty 3) develop alternate assessment methodologies such as professional portfolios, objective structured clinical examination (OSCE).
The National Council of State Boards of Nursing (NCSBN) is in agreement that the entry level assessment for advanced practice nurses should focus on the relatively broad categories of practice i.e. core competencies required for Adult and Paediatric care, and that a focus on specialty areas e.g. diabetes, oncology should be avoided. The NCSBN argument is that an entry level focus on the specialty area may qualify an individual in a specialty, but may overlook the essential knowledge and experience to deal with more commonly occurring health issues.8 The Registered Nurses Association of British Columbia is following a similar path in that the association has identified three streams of nurse practitioner - family (comparable to Ontario's PHCNP) adult and paediatric, and core competencies that are core to all three streams.
The requirement for a consistent academic credential i.e. Masters in Nursing, in addition to an entry examination contributes to public protection by ensuring that students within a nursing masters program attain standard competencies in their selected area of specialty clinical practice, in leadership, in research, in collaboration, and in change agency. The reflective practice and practice review components of CNO's Quality Assurance program can measure the continuous presence of and improvement of competencies specific to the nurse practitioner role - both specialty and general.
These recommendations for broad assessment leave unanswered the issue of specialty recognition and verification. It is next to impossible to design entry level examinations of sufficient regulatory rigour to assess knowledge in every specialty that currently exists, or that may come into existence tomorrow. The cost of doing so would be astronomical, and the numbers within some specialties would be so small that it would be impossible to recoup examination costs. Similarly, the cost of mounting an OSCE for each specialty would be prohibitive, as would the task of assessing individuals' specialty portfolios. The task of separating specialities for assessment purposes e.g. neurosurgical oncology; defining appropriate boundaries of specialty knowledge e.g. cardiovascular disease; and assessing for the exponential growth of the variety of possible specialties is overwhelming from a psychometric perspective.
It can also be argued that competencies required for specialty practice evolve over time and in response to societal health needs, and are subject to continuous modification. It is only through experience that expertise is adapted to meet emerging client or population needs. Therefore any testing that is to be carried out needs to come when the practitioner is well immersed in her/his specialty practice area.
The professional organizations have done a credible job in developing specialty standards for their own specific areas of practice e.g. Emergency Nursing Standards, Canadian Health Executive Standards. CNA, at the national level, has developed professional certification examinations for RNs in the general class (see footnote 8). It would be very consistent, from CNO's regulatory perspective, to be supportive of the development of specialty examinations at the national level by the professional organizations for the advanced practice nurses as well. The path that CNO has followed to date, in contracting out regulatory exams has fostered a climate of "regulatory objectivity" and eliminated the potential perception of bias that could arise if CNO were to develop and administer its own examinations to determine entry into the profession.
Voluntary certification in a specialty area of nursing practice, both for the general class and the extended class may be feasible and in the public interest, when such examinations exist. To require mandatory certification in a specialty when no such certification tool exists is an artificial, nonsensical regulatory barrier. Therefore, the option that will best protect the public is option 1) to remain consistent with current processes and leave the specialty area of practice to a professional certification process and to the academic credentialing process. This option is best carried out by means of the recommendations as listed.
CNO may wish to give future consideration and input to the national development
of professional certification programs in AC/SNP specialty areas of practice
and to encourage AC/SNPs to voluntarily become certified in their specialty
area. At some point, when evaluative data regarding specialty certification
programs becomes available, CNO may wish to consider moving to mandatory requirements
for specialty practice, both within the general and the extended class.
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American Nurses Association (2003, January). Nursing: Scope and Standards of Practice. Public Comment Draft.
Canadian Nurses Association (2002, April). Advanced Nursing Practice: A National Framework. Ottawa.
Centre for Nursing Studies in collaboration with The Institute for the Advancement of Public Policy (2001). Profile of Extended/Expanded Nursing Practice in Canada: The Nature of the Extended/Expanded Nursing Role in Canada. Submitted to F/P/T Advisory Committee on Health Human Resources.
College of Nurses of Ontario (1995, September). Nursing Regulation And Advanced Practice Nursing. The First Question: What Does Advanced Nursing Practice Mean For A Nursing Regulatory Body? Background Paper.
College of Nurses of Ontario (2002). CNO Membership Statistics. Toronto.
Haines, Judith (1993, February). The Nurse Practitioner: A Discussion Paper. Canadian Nurses Association.
International Council of Nurses (2002). ICN announces its position on advanced nursing roles. International Nursing Review, 49, 202, 206.
National Association of Clinical Nurse Specialists (2003). Regulatory Credentialing of Clinical Nurse Specialists. Clinical Nurse Specialist, May, 163-169.
National Association of Clinical Nurse Specialists (2003). NACNS Responds to the National Council of State Boards of Nursing Uniform Advanced Practice Registered Nurse Licensure/Authority to Practice Requirements. Clinical Nurse Specialist, Volume 17 Number 1, 58-65.
National Council of State Boards of Nursing (no date). Facts About Advanced Nursing Practice Regulation. Retrieved 5/2/02 from http://www.ncsbn.org/public/regulation/licensure_aprn_fcts.htm
National Council of State Boards of Nursing (2002). Regulation of Advanced Practice Nursing. Position Paper 1-8. Printed from www.ncsbn.org
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|
Competencies
|
Scope of Practice
|
Class
|
Education
|
Entry Assessment
|
Specialty Recognition
|
| Competencies for RPNs - general practice - specialty-clinical |
Scope of Practice Statement
+ 3 Controlled Acts |
General Class
|
- diploma - continuing ed. |
- nat'l reg exam |
---
|
| Competencies for RNs - general practice - specialty-clinical |
- dip./baccal - continuing ed |
- nat'l reg exam | - voluntary certification | ||
| - Admin - Education - Research |
- baccal/Masters PhD |
---
|
- academic credential | ||
| Competence for Advanced Practice Nursing - CNS |
- masters, post-mastesr |
---
|
- academic credential - voluntary certification |
||
| Competence RN(EC)s - Nurse Practitioners - PHCNP |
+
3 Additional Controlled Acts |
Extended Class
|
- baccal/post baccal | - ECRE | |
| - AC/SNP Adult/Child + specialty area |
- masters, post-masters | - to be developed | - Academic credential - voluntary certification |
||
| - Nurse Anaesthetists | Additional Controlled Acts? | -masters, post-mastesrs |
?
|
?
|
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|
Province / Territory
|
Legislation
|
Title Protection
|
Title
|
Education
|
| British Columbia | Amended Health Professions Act introduced spring
2003, (not proclaimed yet), draft regs to follow. NP core competencies developed, currently being applied to 3 streams of practice |
Has been recommended to government | Nurse Practitioner recommended | No specific educational level identified. Applicants must meet the defined competencies for NP practice. Competencies document acknowledges that the additional NP competencies will usually be achieved through graduate education. |
| Alberta | Currently, NPs are governed by the Nursing Profession Extended Practice Roster Regulation under the Nursing Profession Act, and the Nurse Practitioner Regulation under the Public Health Act. The regs and the NPA will be repealed once the registered nursing profession is proclaimed under the Health Professions Act. | Yes, when legislation is passed | Nurses registered on the Extended Practice Roster will be able to use the protected titles Nurse Practitioner or NP once the regs are passed. | Baccalaureate in nursing, completion of Nurse Practitioner program approved by the AARN, 4500 hrs as an RN. If NP education is more than 2 yr old, must complete a self assessment of competency based on 600 hr in NP role within past 2 yr, verified by independently submitted references from supervisor who has worked with applicant. |
| Saskatchewan | Amended Sask. Registered Nurses Act, 2003, addresses Registered
Nurse (Nurse Practitioner) |
No | Registered Nurse (Nurse Practitioner) | Successful completion of an advanced practice category nursing
program approved or recognized by Council. Successful completion of an exam for advanced nursing practice approved or recognized by Council. |
| Manitoba | Registered Nurses Act, 2001, Board approved reg. governing registration as a Registered Nurse (Extended Practice) and approved RN(EP) competencies Feb 2003. To be forwarded to gov't for approval | No | Registered Nurse Extended Practice RN(EP) | Successful completion of a nurse practitioner
program approved by the Board. Inclusion on the province's registry will be competency based, as opposed to credential based. Must successfully complete a competency based exam. Must meet: Competencies for RN(AP)s Prescribing and Distributing and Guidelines for RN(AP)s Ordering and Receiving Screening and Diagnostic Tests. |
| Ontario | Expanded Nursing Services for Patients Act, 1997 | No | Registered Nurse Extended Class | Baccalaureate, post baccalaureate for PHCNPs. |
| Quebec | January 2003, new legislation enacted for nurse practitioner in specialties - neonatology, cardiology, nephrology - regulations expected in fall of 2003. Regs to be worked on collaboratively with the College of Physicians. There will be a specific register for nurse practitioners. Expect to register first NPs in 2004, mid-year. | No, but ONQ is considering the possibility of asking for legislative amendments for title protection. | Nurse Practitioner | 2 Master's programs - cardiology and nephrology Planning to introduce neonatology. |
| New Brunswick | Nurses Act amended 2002 | Yes | Nurse Practitioner | Part time NP program at UNB. |
| Nova Scotia | Registered Nurses Act, 2002 | Yes | Nurse Practitioner, NP, N.P. | Graduation from a PHCNP program, or an Advanced Nursing Specialty
Program, at the university level. The goal is to have both programs at the Masters level. |
| Prince Edward Island | No - draft legislation on hold, discussion paper on NP role circulated to Medicine and Pharmacy, working on NP competencies | Identified as a priority | ----- | |
| Newfoundland | Registered Nurses Act, Nfld and Labrador Regulation 65/98 2001 | Yes | Nurse Practitioner, NP | Primary - post diploma certificate (political decision initially,
ARNNL's current position is post BN, and the school's goal is post BN). Specialist master's prepared. |
| Yukon | Legislation encompasses expanded role nursing but does not
specifically address nurse practitioner role (may have to change, given
national effort at standardizing entry to practice competencies and national
exam). |
No | ----- | |
| Northwest Territories | NWT Nursing Profession Act, scheduled for third reading June, 2003 | Yes | Nurse Practitioner, RN (NP), NP |