In Ontario, Registered Nurses in the Extended Class, also known as Nurse Practitioners (NPs), are registered nurses with additional education and experience who are able to order and interpret diagnostic tests, communicate diagnoses, prescribe pharmaceuticals and perform specific procedures.
NPs practice nursing, the goal of which is to restore, maintain and advance the health of individuals, groups or communities. NPs use a holistic approach, grounded in research. They emphasize health promotion as well as illness/injury prevention and complement rather than replace the care delivered by other health providers. In addition to providing a wide range of health care services to patients, NPs also help patients to access other health and social services that they may require.
NPs work collaboratively with many other health professionals. In particular, they consult with physicians, as required by the needs of their patients.
As of August 2007, the title Nurse Practitioner became a protected title in Ontario. Only nurses in the Extended Class can use this title. There are four NP specialty certificates in the Extended Class: NP-Primary Health Care, NP-Pediatrics, NP-Adult and NP-Anesthesia.
Primary Health Care NPs generally work in community settings and provide general primary health care services to people of all ages. For many people, primary health care NPs are their first and most frequent point of contact with the health care system. Examples of the types of health care services provided by primary health care NPs include:
Adult and Pediatric NPs tend to work in hospital settings and provide specialized health services to people who have specific health conditions (e.g., neonatal care, cardiovascular disease, diabetes, cancer). Although many of these NPs provide health services to patients who are hospitalized with acute and / or critical illness, they also monitor and treat patients who are ambulatory and living with chronic illnesses.
Examples of the types of health care services provided by Adult and Pediatric NPs include:
All nurses are regulated by the College of Nurses of Ontario (CNO), the regulatory body for nursing in Ontario. The CNO sets the criteria for becoming a nurse in Ontario and the standards of practice that must be met to maintain registration. The CNO’s mandate is to protect the public’s right to quality nursing services .
RNs who meet the CNO criteria and register in the "extended class" have the legal authority to independently perform a number of authorized acts beyond those that registered nurses are permitted to perform. These additional acts include ordering certain diagnostic tests (e.g., X-rays, lab tests, ultrasounds), communicating a diagnosis to patients, and prescribing certain drugs.
NPs are required to consult with a physician if they encounter patient care needs that are beyond their scope of practice.
NPs may also perform other acts that are delegated to them (e.g. performing certain procedures). When delegation occurs, the physician is responsible for the decision to delegate; the nurse is responsible for the performance of the procedure. In addition to ensuring that they are qualified and competent to perform any delegated procedure, NPs are responsible for assessing the availability of any health care procedure or resource that may be required subsequent to, or associated with, implementing a medical directive or delegated act.
As regulated health professionals, all NPs are required to practice according to their legislated scope of practice. However, regardless of the legislation in place or the delegation of certain activities, NPs are accountable to practice according to their individual knowledge, skill and judgment. Where they encounter patient needs beyond their scope of practice, NPs must consult with other regulated health professionals as appropriate. In addition, all nurses are required to participate in CNO’s quality assurance program, which exists to promote and ensure continuing competence among members of the nursing profession.
Nurse Practitioners work in a variety of settings such as community health centres, clinics, urgent care centres, public health units, long-term care facilities and hospital in-patient and outpatient units.
Although primary health care NPs have worked in Ontario since the 1970s, the role was first regulated with introduction of the "extended class" designation in 1998.
According to recent statistics, there were 800 primary health care NPs registered in the extended class and working in nursing in Ontario in 2007.
Adult and Pediatric NPs (formerly known as acute care NPs) have worked in Ontario hospitals since the late 1980s. Interest in the role grew substantially throughout the 1990s, and these NPs are now commonly in academic/teaching hospitals and becoming increasingly common in community hospital settings.
Registered nurses who have: obtained advanced education in the specialty field of their choice (Primary Health Care, Adult or Pediatrics); can demonstrate recent evidence of safe practice; and, have passed an approved registration examination, can apply to the College of Nurses of Ontario to join the extended class.
To be eligible to write the extended class registration exam for primary health care NPs, nurses must first graduate from a CNO-approved education program. The only approved program in the province is the Ontario Primary Health Care Nurse Practitioner Program, a 12-month (full-time) post-baccalaureate certificate program. It is available to registered nurses who meet specific criteria regarding experience levels and previous academic performance.
The Ontario program is offered through a consortium of universities throughout the province. Learners are expected to complete courses in pathophysiology, advanced health assessment and diagnosis, therapeutics, and professional roles and responsibilities. The clinical courses are focused on primary health care service delivery, and the program involves a 13-week, full-time clinical placement in which the student works along side an experienced NP and/or family physician and other team members.
Graduates from some other Canadian NP programs may be accepted to register in the extended class if their education is deemed equivalent to the Ontario program by CNO and they pass all other requirements.
To be eligible to write the extended class registration exam for adult and pediatric NPs, nurses must first graduate from a CNO approved education program. There are two approved Pediatric NP programs in Ontario, delivered at McMaster University (neo-natal program) and the University of Toronto (Child Program) and one approved program for Adult NPs at the University of Toronto (Adult Program). Learners are expected to complete courses in pathophysiology, therapeutics, advanced nursing practice, advanced health assessment and clinical reasoning. Learners must complete a 700-hour clinical placement in an acute care clinical area of their choice.
In addition to the basic competencies required by registered nurses, all NPs are expected to demonstrate the following core competencies of practice upon graduation:
The NP role is well established in Ontario, most other North American jurisdictions and the United Kingdom. There has been extensive research regarding the contributions of NPs to patient care in a variety of practice settings. Studies from multiple jurisdictions have consistently shown that patients are very satisfied with NP services. A 2003 Ontario study showed that 87% of patients surveyed were very satisfied with the care or advice they received from NPs.
Studies also show that patient outcomes are either the same, or improved, when NPs participate in patient care. Some examples of the positive effects associated with NP involvement include shorter length of hospital stay, improved compliance with clinical practice guidelines, better coordination of patient care, lower rates of clinical complications, lower mortality rates and improved interprofessional team collaboration .
Because of their positive contributions and the ability of NPs to improve access to health services, Ontario is increasing the supply of NPs so that more people can benefit from their services.
For more information about NPs visit the following websites: