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The role and scope of the NP in Canada

Alden-Bugden, Donna BSc, BScN, MN, NP, DNP

doi: 10.1097/01.NPR.0000577972.50219.34
Department: Global Perspectives

Donna Alden-Bugden is a family NP in private practice in Winnipeg, Manitoba, Canada (NP Canada Housecalls).

The author has disclosed that she has no financial relationships related to this article.

Historically, the NP role in Canada was informally known as a job for RNs to work in the Northwest Territories, Yukon, and Nunavut under the guidance of standing orders by physicians.1 NPs were not legislated to practice independently. It has only been since the early 2000s that Canada has started to regulate the NP profession. In the late 1990s, NPs were able to fill the void where physicians did not want to work, or they worked in areas along with physicians to enhance patient care. They were still not legislated. Each province slowly developed legislation that allowed NPs to practice independently; however, it was restrictive practice, such as short lists of drugs NPs could prescribe, not being able to order specific diagnostics (computed tomography scans) or having to collaborate with a physician or physicians.

By this point in the US, NPs had been practicing for decades. Canada was learning from the US on how to best utilize the NP role and what the scope of practice (SOP) should include. After a decade of legislation updates, the SOP for NPs in Canada has expanded dramatically. As of 2019, all provinces in Canada have had legislation for NPs for almost 20 years, and the SOP is quite broad in all provinces.2

Advancing the NP role in Canada is essential given the physician shortage and the evidence showing that NPs can be more effective in certain areas of practice.3 Canadian NPs are following the legislative updates in the US and celebrate along with US NPs when positive changes are made to US legislation, allowing NPs full practice authority.

In a 2015 Canadian report outlining the SOP for NPs in Canada, findings showed that nearly all provinces have an expanded SOP, including prescribing controlled substances, not requiring a collaborating physician, treating all diagnoses, referring to all specialists, ordering most if not all diagnostics, performing surgical procedures (for which one has competence), filling out provincial government forms, admitting and discharging to and from some hospitals, and diagnosing any disease.4

NPs in Canada also have connections with the federal government and their agencies and are allowed to assess and sign federal disability forms as well as some other federal forms; however, there are still many federal programs that do not allow NPs to sign their forms. This article will discuss the SOP in the provinces and territories as they relate to the above elements.2

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Overview of NPs in Canada

The average age of a Canadian NP in 2005 was 45.2 years.1 NPs in Canada must have at least a master's degree with a specialization in NP studies and at least 2 years of nursing practice. The first NP program in Canada was established in 1967 at Dalhousie University where RNs were trained to work in Northwest Territories (Yukon and Nunavut) under medical protocols.5 In the 1970s there was a push for more NPs in Canada, but then in the 1980s with an influx of physicians, the NP role was significantly decreased.

As of 2011, there were 27 NP educational programs in Canada.4 Most NPs in Canada practice in a primary care setting, but many provinces have NPs who specialize in pediatrics, neonatology, adult health, or geriatrics. NP positions are mainly in the urban setting, but many positions go unfilled in the rural setting. NPs work in a variety of settings, such as community clinics, mobile clinics, internal medicine, heart failure clinics, transplant units, oncology, ED, neonatology, or in private practice. The Canada Health Act does not restrict NPs from practicing in private practice; however, patients must pay the NP directly, and patients may then be reimbursed for the visit depending on their insurance company.6 Fees can also be used as a deduction on income tax as medical expenses.

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NP SOP in Canadian provinces and territories

Although each Province was asked to complete a survey (compiled by the author) on NP SOP in their respective province, responses were received from 9 of 13 provinces and territories; no responses were received from Prince Edward Island, Yukon, Quebec, or British Columbia. Regardless, it was determined that every province and territory in Canada had legislation to allow NPs to practice at some level. The following section outlines the SOP in nine of the provinces and territories, including Alberta, Saskatchewan, Manitoba, Ontario, Nova Scotia, New Brunswick, Northwest Territories and Nunavut, and Newfoundland.

All nine provinces and territories allow NPs to prescribe controlled substances per federal regulations. Some provinces require extra training before NPs can prescribe controlled substances; some require extra continuing education (CE) or continuing medical education (CME) credits to prescribe methadone, buprenorphine, and also buprenorphine and naloxone (Suboxone). Only one province is still working on allowing NPs to prescribe methadone, buprenorphine, and Suboxone.

Prescriptive authority of general and controlled substances is not restrictive in any of the provinces, and lists are not used. Each province has a vast number of medications that can be prescribed mostly without exception. There are times when exceptional drug status is required, and all nine provinces allow NPs to apply for exceptional drug status.2

Federal laws have allowed NPs to perform medical assistance in dying (MAID).7 Each province has specific details about how it is performed. For example, certain provinces require at least two NPs or one NP and one physician present at the death, whereas others have CE and CME requirements to maintain competency. Most NPs cannot declare the competency of the patient prior to MAID, so they need a psychiatry specialist to rule on competency of the patient.

All provinces allow NPs to practice invasive procedures to their full SOP as long as they have the competency. For example, NPs can learn to do endometrial biopsies, skin biopsies, intrauterine device insertions, incision and drainage, suturing, and the application or removal of casts. NPs must have the competency that usually includes some form of CE or CME and practical experience with a professional.

Provincial regulatory bodies allow admission to hospitals, but each hospital has its own policies on whether it is permitted.2 The College of Nurses may permit admission in some cases, but the hospital may not have a policy to allow NPs to admit to hospitals.

Most provinces do not require the NP to have contracts or a collaborating role with physicians in order to practice. There is only one province (Ontario) that has this requirement, but it is in the process of changing to eliminate this policy. All provinces allow NPs to refer or consult with specialists. Some have restrictions (for example, insurance companies may not pay for a consultation unless a physician sends the referral), but this is a restriction outside of the college of nursing in that province. It is an insurance company policy.

All provinces have a continuing competency program specifically designed for NPs. The requirements are different from RNs and in most cases are more extensive than those required by an RN. Some provinces require the NP to have surveys completed by patients and colleagues, and others require CE or CME along with a certain number of practice hours per year or every 3 years.

Since federal legislation has permitted the legalization of marijuana, most provinces have allowed NPs to authorize medical marijuana for patients with certain conditions. All provinces require some form of CE or CME to ensure the NP has the competency related to medical marijuana.8

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NPs in the US and Canada

The US has had a major influence on Canada regarding legislation and the development of the NP role and SOP. NPs have a vital role in the healthcare system in the US, and the vast numbers of NPs in the US have encouraged Canadian provinces to promote the NP profession. In 2015, there were 4,560 NPs in Canada.4 By 2019, estimates put that number at approximately double the number of NPs practicing in Canada.1 NP utilization is increasing at a progressive rate in the majority of Canada.

The NP role can be expanded in certain areas, including a different payment model for NPs. Fee for services is certainly one model, but many other choices are available. There is a shortage of primary care providers (PCPs), and NPs should be utilized to fill this gap. Too many individuals in Canada are without a PCP, and NPs are well suited for this role. Provinces also need a reentry into practice program so NPs who have been out of practice for a period of time can reenter the profession. With a lack of positions available, some NPs are unable to obtain the required hours needed to be licensed every year, as there is a lack of support for NPs in some provinces. NPs who have been out of the workforce for a while and desire to actively practice again should be able to reenter the profession to fill those positions.

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In summary, the NP role and SOP in Canada have been gradually expanding over time. NPs in Canada and the US must stand together to see progress in the NP profession and become informed about one another's state or provincial legislative happenings. NPs should also advocate for full-practice authority in all provinces, territories, and states. As a coalition, NPs have great power to make change, and change will continue in the near future with enduring motivation.

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2. Donna Alden-Bugden, Personal Communication via a survey, July 5, 2019.
3. Stanik-Hutt J, Newhouse RP, White KM, et al The quality and effectiveness of care provided by nurse practitioners. The Journal for Nurse Practitioners. 2013;9(8):492–500.e13.
4. Agnew Spence L, Fahey-Walsh J. A Pan-Canadian environmental scan of the scope of practice of nurse practitioners. 2015.
7. Government of Canada. Medical assistance in dying. 2019.
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