Originally published January 2014
When working with nurse practitioners, physicians should understand the scope, responsibilities, and accountabilities of these independent healthcare providers, and should communicate clearly and in a timely manner.
While nurse practitioners began working in the Canadian healthcare system in the 1960s, their practice was limited and they worked mostly in remote areas. Since then, their numbers have grown as provinces and territories dedicate additional resources to this profession to meet the challenges of providing care.
Today, there are more than 3,300 nurse practitioners 1 (NPs) across Canada working in community clinics, long-term care facilities, hospitals, and physician-led clinics. All provincial and territorial governments have passed legislation defining and regulating nurse practitioners, and many are increasing funding to train and open new positions for NPs.
For physicians, the increase in NPs reinforces the need to understand and respect scopes of practice, roles and responsibilities, and how best to reduce medico-legal risk when patient care is reliant on multiple providers. While interprofessional care requires effective coordination and communication, the risk of liability can be managed for all health providers. Depending on the legislation in the particular province or territory and the terms of employment, nurse practitioners may provide care in a number of different settings ranging from nurse practitioner-led clinics in rural regions, hospitals, to physician-led clinics located in larger centres. Each situation requires that NPs work within scopes of practice as determined by provincial legislation and, when appropriate, consult with other healthcare providers, arrange for referrals, or transfer care. Nurse practitioners are responsible for the decisions and actions taken within their scope of practice.
Depending on the province or territory and setting where they work, NPs perform a range of clinical duties, such as conduct patient assessments, manage chronic disease, order and interpret diagnostic tests, make referrals, prescribe medications, set fractures, and perform specific procedures. In 2012, Ontario became the first province to allow nurse practitioners to admit and discharge patients from hospital. Other provinces are considering granting this authority to NPs.
Nurse practitioners are regulated independent health professionals licensed by nursing regulatory authorities. These authorities set out the scope and standards of practice of NPs, which can vary according to the specialty of the NP and the jurisdiction. It is important to understand that nurse practitioners are independent health professionals, accountable for their decisions and actions. They are expected to perform their clinical duties within the designated scope of practice and within the limits of their training and experience, usually without medical directive or supervision on the part of a physician. They are also expected to refer patients and to consult with other health professionals when a clinical issue is beyond their knowledge, skill, or competence. They might, in addition, seek a consultation when the presentation is unusual and the patient might benefit from a second opinion.
The courts have stated that physicians working in the context of collaborative practice are not required to check the work of other independent healthcare professionals, such as nurse practitioners, who are providing care within their scope of practice and, generally speaking, each healthcare professional is responsible for the care provided.
However, when a nurse practitioner consults with a physician for assistance or advice in the treatment of a patient, the physician is responsible for the advice and assistance provided to the nurse practitioner and to the patient. This situation is most likely to occur when a clinical condition requires or is expected to require care outside the NP scope of practice or area of competency. In these cases, nurse practitioners remain accountable for their actions, but physicians assume a separate duty of care toward the patient for the care provided as part of the medical consultation and are expected to meet the standard of care for these consultations. Physicians providing advice and assistance as part of these consultations may be deemed to be providing care directly to the patient, and so the physician should document the details in the patient's record as usual.
In Ontario, for example, where NPs can, when authorized by the facility, admit and discharge hospital patients, the principles related to consultation with a physician would apply if the NP seeks advice and assistance for actions that are beyond the NP's scope of practice. However, the NP would be responsible for actions undertaken within the scopes of practice outlined by the jurisdiction and any parameters set by the healthcare facility or hospital. If on discharge the nurse practitioner orders tests for the patient, the NP is accountable for follow-up or taking reasonable steps to determine that there is a reliable system in place for follow-up.
Determining early in the care who is the most responsible practitioner, what is appropriate documentation (including discharge summaries) and, where they are part of the same patient's treatment team, what are the respective responsibilities of the physician and the NP are often key to clarity and continuity of care.
In 2005, the CMPA and the Canadian Nurses Protective Society co-wrote a statement on liability protection for physicians and NPs in collaborative practice. An updated version of this statement is available on the CMPA website [PDF].
Nurse practitioners as part of the healthcare team
Collaborative practice can be defined as the working relationship between physicians, nurse practitioners, other healthcare professionals, and the organization or the facility where they work. It is important for physicians to understand what knowledge and skills are shared among team members and what knowledge and skills are unique to specific individuals on a team. The goal of interprofessional care is to improve outcomes for patients.
There are different forms of collaborative practice. In some jurisdictions, NPs may be required by legislation to establish a collaborative practice relationship with a physician or group of physicians.2 In Ontario, for example, nurse practitioner-led clinics form part of the primary healthcare system. Working with other healthcare professionals, NPs in these clinics provide primary care. NPs run the clinic and consult with part-time physicians on cases that go beyond the scope of practice of the NP.3
In some healthcare facilities, guidelines have been established to outline the requirements associated with NP consultation with a designated physician. Whether a legal requirement, a facility guideline or as an informal practice, NPs consultation with physicians is likely to occur. NPs consult and provide consultations to other healthcare professionals as appropriate to meet a patient's overall needs. Again, each healthcare professional is responsible for the adequacy of the advice and assistance provided to the patient. Physicians providing advice and assistance as part of an NP consultation can be seen as providing care directly to the patient, and so the physician should document the care provided in the patient's record.
When asked for a consultation, a physician should consider:
- reviewing policies related to interprofessional care to be familiar with the scope of practice of NPs
- establishing a mutually agreed upon process for consultation with NPs
- identifying the reason for and the level of urgency of the consultation, if this information has not already been provided
- understanding the level of consultation requested — whether an opinion, recommendation, concurrent intervention, or immediate transfer of care
- seeking the patient's health record to review all relevant medical information, if that it has not already been provided
- documenting in the patient's health record the consultation notes and in a formal consultation report if the physician and NP keep separate patient records.
A referral is a form of consultation and should indicate whether the referral is an episodic intervention or concurrent management during which the NP will continue to provide services within the nurse practitioner's scope of practice. A consultation or referral may result in the need to transfer patient care. This decision should be made jointly by the NP and the receiving physician in consultation with the patient.4
Overlapping scopes of practice
The role of NPs is evolving and depends on a number of factors including jurisdiction, population healthcare needs, and changing practice and healthcare environments.5
As interprofessional practices increase and scopes of practice expand, clear and timely communication is important. Scope, responsibilities, and accountabilities should be understood by all members of the healthcare team to ensure quality care and reduce medico-legal risk.
Increasingly in hospitals and other settings, nurse practitioners and physicians work together to manage on a daily basis the care of the same patient or group of patients. In these circumstances, because physicians and nurse practitioners' scopes of practice overlap, there could be instances in which either the physician or the nurse practitioner could provide the clinical intervention required by the patient, whether this is assessing a change in the patient's condition, ordering the appropriate diagnostic test, following up on a test result or requesting a consultation with a specialist. This is irrespective of the fact the ‘most responsible professional' may have already been clearly identified. A common understanding on the part of all treatment team members as to how responsibilities are allocated between the nurse practitioner and the physician would make it easier to ascertain who is expected to intervene in any given circumstance. This could facilitate an efficient provision of care and avoid potential omissions attributable to either the physician or nurse practitioner proceeding on the mistaken assumption that the other will carry out the necessary intervention.
Integration of nurse practitioners into the healthcare team can help to enhance communication, identify strengths and experience, and encourage a coordinated approach to care. Physicians working with NPs may want to consider the following points;
- Recognize that NPs are independent regulated healthcare professionals accountable for their own professional practice within their defined scope of practice.
- Be familiar with the legislated scopes of practice of nurse practitioners in their jurisdiction. Review the parameters set out by the regulatory authorities.
- Clarify the roles and responsibilities based on the scope of practice and the individual's competence and skill. Determine early in the care who is the most responsible practitioner.
- Review if the hospital or facility, as employer, has formalized and documented collaborative practice procedures, or has policies and procedures that define the parameters of NPs practice.
- Foster a collaborative environment by taking a coordinated team approach to healthcare.
- Verify that systems and processes are in place to support timely and effective communication with NPs and other healthcare professionals. For more information see the article "Strengthening interprofessional communication."
- Communicate to the patient who is responsible for what care. It is important the patient understands the respective roles of the NP and the physician. Clarify how patient expectations or concerns will be managed.
Whether in primary care offices, clinics, or hospital settings, all members of an interprofessional team should have appropriate and adequate liability protection. Members who have questions on interprofessional care and working with nurse practitioners may call the CMPA to speak with a medical officer. Additional information on interprofessional care, the most responsible practitioner, and improving communications can also be found on the CMPA website.
Compilation of statistics from the nursing regulatory bodies provided by the Canadian Nurses Protective Society.
College of Registered Nurses of Nova Scotia, "Guidelines for Collaborative Practice Teams and Employers of Nurse Practitioners: Strategies for Integrating Nurse Practitioners in Healthcare Teams" January 2012. Retrieved on January 12 2013 from: http://www.crnns.ca/documents/GuidelinesforCollaborativePracticeTeamsFINAL-2011.pdf;
Registered Nurses Act, SNS 2006, c. 21, s. 1(ak); (http://canlii.org/en/ns/laws/stat/sns-2006-c-21/latest/sns-2006-c-21.html)
Nurses Act, S.N.B. 1984, c. 71, as amended, s. 10.4; Regulation respecting the activities contemplated in section 31 of the Medical Act which may be engaged in by classes of persons other than physicians, RRQ, c M-9, r 13; (http://www.hprac.org/en/projects/resources/hprac-nursing.jurisdictionalreview.november2007.final.pdf)
Nurse Practitioner Regulations, PEI Reg EC91/O6, s. 6; (http://www.canlii.org/en/pe/laws/stat/rspei-1988-c-r-8.1/latest/rspei-1988-c-r-8.1.html)
Registered Nurses Regulations, NLR 66/13, subs. 8(3). (http://beta.canlii.org/en/nl/laws/regu/nlr-65-98/latest/nlr-65-98.html)
- Canadian Health Services Research Foundation, "Clinical Nurse Specialists and Nurse Practitioners in Canada – A Decision Support Synthesis," June 2010. Retrieved on January 15 2013 from : www.chsrf.ca.
- College of Nurses of Ontario. "Practice Standard; Nurse Practitioner," revised 2011. Retrieved on January 9 2013 from: http://www.cno.org/Global/docs/prac/41038_StrdRnec.pdf
- Canadian Nurses Association, "Canadian Nurse Practitioner – Core Competency Framework" May 2010. Accessed on February 12, 2013 from: http://www2.cnaaiic.ca/cna/documents/pdf/publications/competency_framework_2010_e.pdf