The hospital-based nurse practitioner: Context, scope of practice and competencies

The purpose of this document is to provide some  context on NP practice in Ontario, and to discuss the specific competencies of NPs in the hospital setting. Nurse practitioners are expert clinicians that provide essential health services within a framework of advanced nursing practice, specialty knowledge and skills [1]. Nurse practitioners work in a  variety of settings, including hospitals, primary care, home health, rehabilitation, public health, and long-term care.

See a chart comparing of hospital-based health-care providers.

Nurse practitioner practice is authorized by a legislated scope of practice[2]and includes:

  • Assessment
  • Ordering diagnostic tests
  • Communicating a diagnosis
  • Therapeutic treatment
  • Prescribing medications
  • Management of acute and chronic illnesses
  • Consultation and collaboration with physicians and other inter-professional team members
  • Admitting, treating and discharging hospital in-patients

Nurse practitioners provide comprehensive care to hospital patients, including the treatment and management of acute and chronic illnesses. They are completely accountable for the autonomous care that they provide. They consult and collaborate with physicians and other inter-professional team members as needed to optimize care. NPs also provide leadership within teams including the development, implementation and evaluation of strategies to promote health and prevent secondary and tertiary illness and injury.

Nurse practitioners as advanced practice nurses

NPs have an expert knowledge base, complex decision-making skills and clinical competencies [1]. NPs analyze and synthesize knowledge, understand, interpret and apply nursing theory and research and assist in developing and advancing nursing staff, contributing to nursing knowledge and to the profession as a whole [3].

See Canadian Nurses Association Position Statement on Nurse Practitioners, 2009

College of Nurses of Ontario data

As of May 2015, there are 2624 NPs registered with the College of Nurses of Ontario [4] Nurse practitioners can register with the CNO under three recognized specialty categories: primary care, adult or pediatrics. A fourth specialty, NP anaesthesia, currently has no registrants.

Table 1: Nurse practitioner numbers in Ontario by specialty [4]

(Note: NPs may register in more than one specialty)


Number of NPs

Percentage of total

Primary Health Care





19 %



8 %





Get the practice resources to guide NP practice in Ontario.

The nurse practitioner role:

Under the Public Hospitals Act Regulation 965, subsection 1(1), nurse practitioners are defined as "extended class nursing staff".  Registered nurses in the extended class (aka nurse practitioners) work in a hospital setting as either:

  1. Employees of the hospital
  2. Non-employees who are granted hospital privileges by the hospital board (Professional Staff NPs)[5]

Under the Public Hospitals Act, NPs are authorized to care for patients that are admitted to hospitals, including admission and discharge. For more information, please see the section of this toolkit titled "Legislation and Regulation ".

Nurse practitioners working in hospitals perform a variety of roles, including: [6]

  1. Clinical care
  2. Research
  3. Education
  4. Administration (e.g. Quality improvement projects)

See a sample role description of an NP at Lakeridge Health in Whitby, Ontario.

Nurse practitioner competencies [7]

(Based on the Canadian Nurses Practitioner Core Competency Framework; CNA, 2010)

Professional role, responsibility and accountability

The NP:

  • Provides leadership in the management of clinical care, is a resource person, educator and role model.
  • Acts as a preceptor, mentor and coach.
  • Collaborates with members of the health-care team to provide and promote inter-professional client-centred care.
  • Applies advanced knowledge and skills in communication, negotiation, coalition building, change management and conflict-resolution.
  • Acts as a change agent.
  • Advocates for an organizational environment that supports safe client care, collaborative practice and professional growth.
  • Provides leadership in the development and implementation of standards, policies, practice guidelines, quality assurance, and education and research initiatives.
  • Integrates the principles of resource allocation and cost-effectiveness into clinical decision-making.
  • Promotes safe client care.
  • Consults with other health-care providers when the client’s condition is not within NP scope of practice or competence.

Health assessment/diagnosis/therapeutic management

The NP:

  • Performs comprehensive health assessments (focused or comprehensive).
  • Diagnoses diseases, disorders, injuries and conditions.
  • Prevents, anticipates, diagnoses and intervenes to manage emergent, urgent and life-threatening situations.
  • Orders and or performs diagnostic investigations, interprets results using evidence-informed clinical reasoning and critical inquiry, and assumes responsibility for follow-up.
  • Communicates with patients and families diagnosis, including outcomes and prognosis.
  • Develops therapeutic plans with patients, families and inter-professional team using evidence-informed practice.
  • Supports, educates, coaches and counsels clients regarding diagnoses, prognoses and self- management.
  • Prescribes pharmacotherapy, applying evidence-informed practice in prescribing, monitoring and dispensing drugs,
  • Counsels clients on medication therapy, benefits, potential side effects, interactions, importance of compliance and recommended follow-up.

Health promotion and prevention of illness and injury

The NP:

  • Develops, implements and evaluates strategies to improve/restore health.
  • Identifies clinical and system issues and trends.
  • Prevents and manages nosocomial complications.
  • Optimizes management of acute and chronic illness.
  • Implements evidence-based best practices, for example:           
    • Antimicrobial stewardship
    • DVT prophylaxis
    • Delirium prevention
    • Falls prevention
    • Prevention of urinary-tract infections
    • Prevention of pneumonia
    • Pressure ulcer prevention
    • Prevention of hospital-association de-conditioning
    • Restraint-use minimization


  1. DiCenso, A. and D. Bryant-Lukosius, Clinical Nurse Specialists and Nurse Practitioners in Canada: A Decision Support Synthesis. 2012, Canadian Health Services Research Foundation.
  2. College of Nurses of Ontario. Practice Standard: Nurse Practitioner. 2011.
  3. Canadian Nurses Association. Position Statement: The Nurse Practitioner. 2009, Canadian Nurses Association: Ottawa, Ontario, Canada.
  4. College of Nurses of Ontario. Membership Totals at a Glance. 2015  [cited 2015 May 29]; Available from:
  5. Ontairo Hospital Association. Enabling Nurse Practitioners to Admit and Discharge: A Guide for Hospitals. 2012.
  6. Kilpatrick, K., et al., How are acute care nurse practitioners enacting their roles in healthcare teams? A descriptive multiple-case study. International Journal of Nursing Studies, 2012. 49(7): p. 850-862.
  7. Canadian Nurses' Association. Canadian Nurse Practitioner Core Competency Framework. 2010, Canadian Nurses' Association: Ottawa, ON.