Happy Hosptialist Rant: Nurse Practitioners are not Doctors

I just finished reading a post on the Happy Hospitalist blog on a friend’s suggestion.

The hospitalist is upset at a potential blurring of lines between NPs and Doctors, at least in the eyes of the public. He or she worries that patients will be at risk because they won’t know the difference between their NP and their doctor. It would however have to be ongoing and intentional misrepresentation by the NP to be damaging to the patient. An unlikely scenario.

Anyway, one of the key elements of the Hospitalist’s argument is that differential diagnosis is the great divider between disciplines (at least in the eyes of the public). A differential diagnosis is a systematic method used by physicians to diagnose based on symptoms. The  nursing equivalent is what is known simply as nursing intuition.

Kim, an RN, replied to the Happy Hospitalist post: “I appreciate the inability to articulate the differential diagnosis process because I have difficulty articulating the “gut” feelings and intuition that come only with years of practice as a registered nurse. Thousands of hours of taking care of patients. For you, you can name fifty differential diagnoses. For me, it means knowing long before any “quality indicators” suffer, that my patient is sinking.”

The point being is that there are many differences between nursing and medicine. What the blogger seems to completely miss however is that each discipline has a role to play.  There is no reason why one discipline cannot balance the other. It’s what doctors and nurses have been doing all along after all.

But this blogger seems to fear the points where the two specialties meet and at times cross. Boiled down, I think the post is simply a territorial rant over long disputed nurse/doctor boarders that states a rather obvious point: NPs and doctors are different. Go figure.

I believe the blogger speaks from a US health care perspective where NPs have a much broader  interhospital-role than they currently do Canada. However, there is no doubt that Canada will see an increasingly stronger NP role being played out in public health care. Canada is also seeing and will see its fair share of territorial disputes in this area.

The most important point I realized in all of this is that health care can no longer be supported by only one discipline and there is ample room, as well as great need, for others to share responsibility.  There is also no reason why each discipline can’t work and grow together.

Nursing Careers: Becoming a Nurse Practitioner in Ontario

Nursing Careers is an ongoing series that explores different career paths available to student RNs.

What is a Nurse Practitioner (NP)?

The first thing I discovered about the title “Nurse Practitioner” is that it is commonly used in Canada to identify a wide variety of advance practice nursing (APNs) roles but has no official definition on its own. The actual title of Nurse Practitioner is not specifically protected under current Canadian law and, therefore, holds a variety of different meanings. The definition of nurse practitioner is commonly further classified by province or territory. In addition, in medical literature, the title “Advanced Practice Nurse” is often used interchangeably with “Nurse Practitioner”.

Title protection, as well as regulation of NPs, falls under the jurisdiction of provincial and territorial nursing regulatory bodies. In most provinces there is no restriction on the use of the title. The CNO, for example, state Registered Nurses in the Extended Class [RN(EC)s] are also known as Nurse Practitioners, in the public interest (link).

The NP role has existed in Canada since 1967. In the early years, when you called someone a nurse practitioner, you were referring to them as a RN who worked in ambulatory or outpatient clinical settings such as public health, clinics and physician offices (source). Also, in Ontario, NPs were originally trained to provide primary health care in northern remote communities (source). Currently, NPs are recognized as having acquired additional education, knowledge, skills and expertise. beyond the role of the RN. Also, in their expanded scope of practice, NPs commonly perform tasks that have traditionally been considered only in the domain of physicians.

Titles used by NPs in Canada include:

• Primary Health Care Nurse Practitioner (PHC NP)
• Registered Nurse-Extended Class (RN[EC])
• Acute Care Nurse Practitioner (ACNP)
• Clinical Nurse Specialist/Nurse Practitioner (CNS/NP)
• Nurse Practitioner-Specialist (NP-S)
• Specialty Acute Care Nurse Practitioner (SACNP).

Source: Nurse Practitioners’ Association of Ontario

Example of the Nurse Practitioner scope of practice:

• diagnose and treat illness and/or injuries
• perform physical check-ups
• order and interpret diagnostic tests
• write prescriptions
• provide counselling and education
• provide supportive care through illness
• provide treatments and/or procedures
• make referrals to family physicians, specialists and
  other health professionals.

Source: Nurse Practitioners’ Association of Ontario

Education

A list of various Nurse Practitioner Certificate programs approved by the CNO can be found on the CNO web site here. This includes the primary health care, adult and paediatric specialty programs.

It is important to note that in Ontario a graduate level degree is not required to hold a Nurse Practitioner Certificate. In fact, the CNO does not distinguish between a master’s NP and a postbaccalaureate NP. Instead, the CNO requires that Extended Class nurses write an approved exam to assess core competencies (source).

On the other hand, holding a master’s degree does create one of the career path divisions under the umbrella term “Nurse Practitioner”. Acute Care Nurse Practitioners (ACNPs) are registered nurses who have a master’s degree from a recognized acute care nurse practitioner education program in Ontario or its equivalent (source).

To make things a bit more complicated, many universities are offering a combined masters/NP program. York University, for example, offers a combined Primary Health Care Nurse Practitioner (PHCNP)/Masters Program (link). A PHCNP however is not the same as an ACNP. The difference is based on the education provided but not in the term “Nurse Practitioner”.

An NP can hold a specialty certificate in one or more of the following areas:

• Nurse Practitioner-Primary Health Care (NP-PHC)
• Nurse Practitioner-Paediatrics (NP-Paediatrics)
• Nurse Practitioner-Adult (NP-Adult)
• Nurse Practitioner-Anaesthesia (NP-Anaesthesia) (**see Nursing Careers: nurse anesthetist)

Source: Nurse Practitioner Practice Standards

Additional Reading:

• To learn more about a ACNP click here.
• To learn more about a PHCNP click here.
• To learn more on PHCNP university programs click here.

Related web sites

• Nurse Practitioners’ Association of Ontario
• College of Nurses of Ontario
• Nurse Practitioner Practice Standards
• Ontario Primary Health Care Nurse Practitioner Education Consortium
• Canadian Nurse Practitioner Initiative
• The Nurse Practitioner’s Place

In future posts, I will focus specifically on the role of Nurse Practitioner Primary Heath Nurse Practitioner (PHCNP) and Acute Care Nurse Practitioners (ACNP).