Physician Assistants & Nurse Practitioners: Similarities in Differences in Canada
PAs and Nurse Practitioners are advanced practice providers providing care to patients. Here we compare the roles in Canada, with a focus in Ontario. This was written with information from a 2019 phone interview with Claudia Mariano, MSC, NP-PHC, CDE Manager, Practice and Policy Nurse Practitioner’s Association of Ontario.
PA vs. NP - Overview of Differences
Physician Assistants:
Educated in the medical model
Bachelor or Masters in PA Studies
Regulation is dependent on jurisdiction
Non-independent practitioner (works in collaboration with a supervising physician)
Practices in all areas of medicine
Nurse Practitioners:
Educated in the nursing model and medical model
Bachelors in Nursing, then Masters in NP Studies
Regulated health care professional
independent practitioner - can act independently from a physician and run their own clinics
Practice in all areas of medicine, with specialty dependent on NP-stream (e.g. NP-Adult, NP-Paediatrics)
In this post:
I. Definition of PA and NP
a) What is a Physician Assistant?
Physician Assistants are highly skilled health care professionals educated in the medical model who practice medicine.
They graduate from a Baccalaureate or Master’s Degree program that may be affiliated with a medical school. PAs practice medicine under the supervision of a licensed physician within a patient-centered health care team. PAs can work in any clinic setting to extend physician services, complement existing services and aid in improving patient access to health care.
PAs conduct histories, physical examinations, order and interpret investigations, perform diagnostic and therapeutic interventions, diagnose and treat illnesses, and educate patients on treatment options and counsel on preventative health
PAs assist in surgery, prescribe medications, and perform procedures that fall within their scope of training and experience, as long as it falls within the scope of their supervising physician
A PA’s practice mirrors that of their supervising physician
PAs work to extend physician services, but are not independent practitioners
b) What is a Nurse Practitioner?
Nurse Practitioners (NP) are registered nurses, with some working years of experience who has completed graduate level of education to provide health care to patients[1].
The Nurse Practitioner program is a Master’s level program. NPs also write another licensing exam to practice as Nurse Practitioners.
NPs have a scope of practice that is broader than what they are able to do as Registered Nurses (RNs). NPs have additional authority including diagnosing, admitting patients, treating and discharge patients from hospital. NPs can also order diagnostic tests, and lab tests. NPs can work independently without a supervising physician. In Canada, Nurse Practitioners can also prescribe all medications including controlled substances and Narcotics.
[1] NPAO. What is a Nurse Practitioner? https://npao.org/about-npao/what-is-a-np/
II. Misconceptions about PAs and NPs
Physician Assistants are often confused for “doctors in training”, administrative assistants/medical secretaries, or other clerk-like roles because the name “assistant” is misnomer.
PAs are advanced practice providers who practice the same medicine physicians do, but do so in collaboration with/under the supervision of a physician.
The patient may see the PA without seeing the physician, or see the PA and MD in one visit depending on the setting, practice, and workflow.
Nurse Practitioners - Some patients think that you need to see the MD once the Nurse Practitioner has finished assessing you.
As long as the condition or presentation falls within an NP’s scope of practice, knowledge and judgement, NPs can see a patient without physician involvement. If not within their scope of practice, the Nurse Practitioner will make the appropriate referral when it is outside their scope of practice just as a family physician would.
III. History of PAs and NPs in Ontario
Physician Assistants have been in Ontario since 2007 at the start of the Ministry of Health and Long Term Care for Ontario (MOHLTC) as part of a PA demonstration project to evaluate impact of PA’s in Ontario recruiting Internal Medical Graduates (IMGs) and PAs trained in the US.
They have been supported by the Ontario Medical Association since their introduction to Ontario.
In 2008, two PA education programs were launched by McMaster University and PA Consortium (University of Toronto Medicine, Northern Ontario School of Medicine and Michener Institute of Applied Health Sciences).
Military-trained PA’s have been working in the Canadian Forces for over 50 years graduating from the Canadian Forces Medical Services School at Borden, Ontario.
Learn more about the history of PAs in Canada at the CAPA website.
Nurse Practitioners have a 40-year-history of working in Ontario (since the 1970s). They were originally pioneered to expand the RN role in remote communities in Ontario.
The Nurse Practitioner profession began in Community Health Centres (CHCs), with its origins being Registered Nurses practicing with an expanded scope to serve the needs of patients in rural communities. Although not called NPs at the time, the work these RNs did resembles what NPs do today.
Learn more about their history at the NPAO website.
IV. Education of PAs and NPs
Physician Assistants:
To become a PA, you are required to complete a minimum of 2-4 years of a university undergraduate degree (with some “recommended” courses), a minimum GPA, and if you are interested in PA Consortium (University of Toronto, NOSM, and Michener) then you are required to have hours of health care experience (which is not a requirement of all PA schools, but there are many examples of PAs who had previous health care experience before becoming PAs). You also require a GPA of 2.7-3.0 or higher on the OMSAS scale. You do not need a science undergraduate degree to apply to the program. Nurses may also apply to become PA’s.
In Ontario, there are two schools that offer PA programs, both are Bachelor’s degree in PA studies. Manitoba’s PA program offers a Master’s Degree.
Education is based on the medical model
The program length is 24 months. The first 12 months include basic medical foundations, and the second year consists of clinical rotations through different areas of medicine. You cannot bypass any aspect of this training, and this applies irrespective of your experience or background.
PA education is not tiered. Once a PA graduates, they are open to practice in any area of medicine (whether surgical, generalist or non-surgical specialties).
Nurse Practitioners:
NPs must complete a Bachelor in Nursing first, then apply to a Master’s in Nurse Practitioner studies. The NP programs are competitive to get into and requirements differ between different programs. An example of what they may require includes: minimum 2 years of direct RN nursing experience in the last five years (3640 hours) with a GPA of B or higher in an undergraduate nursing program.
There are three different specialty certificates (Primary Health Care, Adult and Paediatrics) with different universities offering the different programs (NP-PHC, NP-Adult, NP-Paediatrics).
There are several schools in Ontario that offer the primary health care NP program, admission requirements differ between each school. At time of writing they include: Lakehead University, Laurentian University, McMaster University, Queen’s University (satellite site: Trent University), Ryerson University, University of Ottawa, University of Western Ontario, Windsor University and York University.
9 of these schools provide NP-PHC (Nurse Practitioner – Primary Health Care) as a consortium of education, so you receive the same education if you take this track regardless of which university you attend.
University of Toronto is the exception as they have their own NP-PHC / primary care program which they call a global health program.
University of Toronto also has an NP-Adult and NP-Paediatrics certification, which leads to NP jobs primarily in hospital.
Education is based on the nursing model AND the medical model. You can learn about course material here.
Study is 2 years, consecutively. Education includes practicum placements, clinical placements and didactic classroom work.
In Ontario, the NP-PHC is a hybrid program, with some courses done online and a requirement for weekly on site sessions.
For the University of Toronto PA program, NP-PHC is essentially online but students are required to be on site in Toronto 1-2 weeks at a time at least twice each year for more intensive parts of the curriculum.
V. Nursing Model vs. Medical Model
Physician Assistants and Physicians learn from the medical model, or what is traditionally thought of as the “disease” model of learning medicine.
This includes approaching disease from the perspective of basics of anatomy & physiology, pathophysiology, pathology, pharmacology, epidemiology, etiology, investigations, clinical presentation, and treatment.
To explain the medical model, we first have to look at a little bit of history to understand where this model comes from. The “old medical model” as described by psychiatrist Dr. George Engel in 1977, is a disease-oriented model which describes disease is a result of abnormal biological functioning (deviation from normal anatomy, physiology & molecular biology)[2]. Restoration to normal functioning relied on the physician to correct the abnormality.
Jonathan Fuller in a 2017 paper titled “The new medical model: a renewed challenge for biomedicine”, he describes a newer medical model that incorporates prevention of chronic disease, and use of evidence-based medicine. And evidence-based medicine is in reference to clinical research, epidemiological evidence. The goal of the new medical model is to “cure, prevent or manage the disease”.
In combination with the PA/MD’s assessment – patient history, physical examination, ancillary investigations, the physician/PA can diagnose the underlying problem and correct the dysfunction with a treatment plan (which may include different treatment modalities – patient education, counseling, therapeutic procedure, medication, encouraging lifestyle changes, topical or oral medications, injections, etc.)
Medical and PA programs today have moved towards patient centered, and interdisciplinary care, and away from physician paternalism.
[2] Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129–36
Nurse Practitioners learn in the nursing model and medical model.
The nursing model is the foundation of holistic, whole person care. There is a biopsychosocial approach looking at patient needs across the whole spectrum – from cradle to grave regardless of diagnosis. And with training as nurses first, NPs focus on those patient needs, and not just the medial diagnosis.
When completing the Nurse Practitioner education program, students begin to focus on assessing, diagnosing and treatment disease, with some of the basic medical foundations but coming at it with a nursing focus.
VI. Licensing and Re-certification for PAs and NPs
Physician Assistants are qualified to write a licensing exam once they complete their PA certification.
From there PAs have to meet annual minimum requirements of Continuing Professional Development (CPD) credits in the form of hours spent in coursework, conferences, working towards a Master’s, journal reading, and more.
Once PAs are Canadian Certified Physician Assistants (CCPAs), they do not need to write a re-certification exam.
For Nurse Practitioners once you are certified there is no re-certification exam to be completed.
In the province of Ontario, NPs have mandatory Quality Assurance (QA) Programs, we do have to do annual QA as per regulatory programs. Each province will have its own QA program. In Ontario, every regulatory health college is legally required to have a QA process. In Ontario, CNO has one that NPs are required to participate in annually, and may include an OSCE for some.
CNO is part of the QA program. NPs are expected every year to complete a learning plan, and in the process identify areas they need to expand their knowledge and skill in. And based on their r learning to participate in continuing education activities.
CNO requires nurse practitioners to maintain patient contact in a clinical setting in order to keep their license.
VII. Funding for PA and NP Jobs
Physician Assistant Funding
PA funding can come from several different areas: out of physician pocket (whether this is solo physician practice or a group practice where several MDs share cost of hiring a PA), grants from the government, hospital budget, department budget (within a hospital), grants from specialty associations/organizations, and LHIN funding just to name a few. PA jobs can be funded by one source, a combination of the above.
PAs cannot bill OHIP independently (they do not have billing numbers) and according to the Ontario Schedule of Benefits which is a document that outlines how Ontario physicians are paid in a fee-for-service model – a physician cannot bill for the service rendered by a PA unless they had meaningful participation in that patient encounter.
Nurse Practitioners work in positions that are funded by the Ministry of Health, and include Community Health Centres, Family Health Teams or Nurse Practitioner-led clinics.
The funding for those positions in the community has been relatively stable for a few years as well. So unless someone leaves a stable position, new grads are in waiting to take that position.
VIII. Employment Opportunities for PAs and NPs
Physician Assistant Job Outlook
We have seen some growth in the PA profession with regards to jobs, especially for new PA graduates. However, like most publicly funded healthcare positions, funding and budgeting available for healthcare impacts the availability of jobs. Most employment opportunities are found through networking and internal job postings (many are not listed on public job listing sites like Indeed).
Nurse Practitioner Job Outlook
It is also common for NPs to obtain hospital positions, as there are extended benefits that may be more competitive than community or private settings. These positions may or may not be cut in order to save money in a certain area or to balance a budget. This can occur whenever hospitals cut nurses, as NPs can be part of that too. Hospital positions may also be unionized. Opportunities also exist in LTC, rehab, addiction and mental health facilities, home care, and palliative care.
IX. Opportunities for Growth
Physician Assistants can be involved in teaching, research, medical writing, administration, leadership, patient and PA advocacy, entrepreneurship and more.
Nurse Practitioners are able to get involved teaching through NP programs which is certainly an area.
Many NPs work in long term care, and palliative care. In Ontario, NPs can provide medical assistance in dying, providing very important work to those who choose to end their lives at a certain time. Some palliative care teams have Nurse Practitioners as well.
X. Q&A with a Nurse Practitioner
Q. How do you explain the difference between an MD and NP?
I tell patients now that it is easier to discern MD vs. NP by what we cannot do – which will vary by jurisdiction. In Ontario, we cannot order CT/MRI. Though that legislation was passed over 10 years ago it still has not been proclaimed.
Scope of practice and degree of autonomy also depends on the knowledge skill and judgement of the individual nurse practitioner, just as with any professional.
Physicians have a broader and deeper experience and education related to illness and diagnoses, which is absolutely needed. Just as family physicians refer to specialists, when the family doctor has gone beyond their knowledge and skill, nurse practitioner will refer to their knowledge skill and judgement. It will certainly depend on the nurse practitioner.
NPs work in palliative care and end of life care, in addictions and mental health, and may have more comfort prescribing many medications for pain management, than some physicians have, because that was their area and knowledge.
Q. How is the Role Different from an RN? from an RPN?
Scope of Practice is determined by each province:
Registered Nurses (RN): University Level Education – Degree. More taking care of patients, including patients who aren’t quite stable. The RN position includes responsibilities that may require critical thinking.
Registered Practical Nurses (RPN): College Level Education – Diploma. RPNs deal with patients who are stable, who have predictable and expected health care needs related to whatever their condition
Q. What do you find challenging about being an NP?
There are some limitations, as Nurse Practitioner are employees. In primary care, you are hired as an NP-PHC in CHC, FHT or employed by a hospital. We’re still employees, and expected to function in a certain way, and an employer may not allow us to work to the full scope of practice as a nurse practitioner. Working with an NP can make the physician’s life easier, and can help a physician make some more money. However, in this scenario the NP may not be necessarily practicing to the top of their scope of practice. That can still be constrained.
In a NP-led clinic everyone is working to full scope of practice. This can be the case also if there is NP role clarity in other settings.
Q. What steps should an MD take if they are interested in working with a Nurse Practitioner?
It is not as common for MDs to work directly with NPs because in this instance the MD would have to pay the NP out of pocket. It does happen, and physician can take more time off and take on new patients, and more comprehensive services. There are other benefits, and quite a few Nurse Practitioners who choose this route.
Q. RNs are obtaining prescription rights in Ontario – does the blur the line between the NP and RN role when it comes to role clarity?
I don’t think so, it’ll be quite specific. There will likely be certain instances that those prescriptive rights are allowed. For example, RNs administer immunizations all the time, and there should be no reason that RNs can’t prescribe immunizations. It is up to CNO to put specific regulations in place that will clarify when RNs are able to prescribe.
Years as ago when I was working in a sexual health clinic as an RN, there was no reason I wouldn’t have the knowledge to prescribe antibiotics for the STDs since I was able to diagnose and manage these conditions – but as an RN I did not have the scope of practice to do so. Extending these prescriptive rights would be appropriate in examples such as these to help expand access for patients in rural and remote areas.
Q. What are differences between Canadian and American Nurse Practitioners?
In America, how Nurse Practitioners are utilized differs between each state, just as in Canada Nurse Practitioner utilization differs by each province and territory. Funding for Nurse Practitioners is different in the US because they do not have universal health care model. There are many states where NPs are fighting for prescriptive authority, and for many of the authorities that Nurse Practitioners have here.
Q. Can Nurse Practitioners cross Provinces?
Because health care is the provincial initiative, in every province you must be registered by that regulatory body. This process involves showing the NP regulatory body proof of your education to ensure there are no restrictions on your license. This does not involve re-writing any kind of licensing exam, as your NP license is portable between provinces and territories
Q. Is there an adversarial relationship between Nurses and Physician Assistants?
I’ve always believed there is more than enough work to go around – especially when it comes to patient care. There is a role for Physician Assistants, Physicians and Nurse Practitioners to treat patients.
Health care providers can get stuck feeling threatened by other health care providers. But if we understand that every health care provider is a legitimate provider with a skillset, education, knowledge and ability to improve health care – patients can benefit.
Funding models are the biggest barriers, and it really impacts health care – this is where the balance of power resides.
Regardless of the title, let’s have people work to the top of their scope of their practice. We don’t need to be fighting over it – we all have our particular area of expertise, and we’re all working towards the same goal of treating patients – we should not start throwing each other [health care providers] under the bus.
Q. How did the Nurse Practitioner profession successfully integrate itself into Canadian Health Care system? Especially since it was a new and innovative role at the time!
There is a LOT of data that points to strong outcomes, and great patient outcomes. As annoying as it was to have to consistently prove our value, we have solid research that show NP involvement improves care.
Patients were also really happy the care that they received from Nurse Practitioners. Feedback from patients was extremely positive. Patients feel they are getting good care and that does change the conversation.
I published a book a few years ago highlighting the NP role in different settings across Canada. The role started when the NDP government of the day decided to open the NP program again in the 80s, because the health minister, Ruth Grier, was so impressed with the care she received at a CHC, and she felt this should be an option for more people. I talk about this a bit in the book – https://books.friesenpress.com/store/title/119734000016352374/Claudia-Mariano-No-One-Left-Behind
Q. How did you get that body of evidence to prove the value of Nurse Practitioners?
The body of evidence to prove the value of Nurse Practitioners comes from science-based research organizations. Some studies were government funded because they wanted to look at different models of care, some of these came from Canadian Institute for Health Information (CIHI), and some from the American studies on utilization and value of Nurse Practitioners. A lot of the research initially came from US studies as they have been utilizing NPs for a long period of time.
Health Quality Ontario has an annual report every year, and there are items in the annual report about nurse practitioners. Patients do fare better when working with a nurse practitioner
Q. Are nurses unionized? And therefore Nurse Practitioners unionized?
If a nurse is hired through a hospital, they are likely unionized (Ontario Nurses Association – ONA). I’ve never practiced as part of a union and as most of my career has been in primary health care and Public health units.
NPs who are hospital employees are likely unionized as well.
There are no restrictions on NP practice and any “restrictions” (e.g. hours worked) purely depends on what is negotiated individually. There has NEVER been a stipulation for maximum number of patients seen in a day by a Nurse Practitioner.
If a nurse is part of a managerial role, then they are likely not unionized.
Claudia Mariano graduated from the University of Toronto in 1986 with her Honours Bachelor of Science in Nursing. After working in medical-surgical nursing and public health nursing, she returned to U of T and obtained her Master of Science in Nursing in 1992.
In 1999 she graduated from the Primary Care Nurse Practitioner Program, also from U of T. Since that time she has embraced primary care and chronic disease management, working at the East End Community Health Centre in Toronto for 10 years, and for the past 10 years at the West Durham Family Health Team in Pickering. Claudia is a Certified Diabetes Educator and has obtained her certificate in Intensive Smoking Cessation Intervention. She is also a trainer for the Ottawa Model for Smoking Cessation. Her clinical practice is heavily focused on health promotion and self-management of chronic disease.
Claudia is a Past President of the Nurse Practitioners’ Association of Ontario and current NPAO Board member, past Board member of the Association of Family Health Teams of Ontario, current Adjunct Lecturer at the University of Toronto Lawrence S. Bloomberg Faculty of Nursing, and author/editor of ‘No One Left Behind: How Nurse Practitioners are Changing Canada’s Health Care System’.
