The following was condensed by Ms Scarrow for Viewpoint from an article which appeared in Registered Nurse Journal May/June 2009

Nurse practitioners (NP) across Ontario are improving access to care despite restrictions on their practice that hold them back from their full potential.

By the time Dolores Southward learned about Canada's first nurse practitioner-led clinic opening in Sudbury in 2007, it had been more than a year since she'd had a regular health-care provider. After her doctor moved away in 2006, Southward relied on walk-in clinics to renew her hyper-tension medication. That meant spending hours in a waiting room just for a few minutes with a physician who quickly signed the prescription pad. That's why, even though Southward didn't know anything about nurse practitioners, when she heard a news story about the local clinic she decided to try it out. "I thought, I have no doctor, I'm going to take a chance," she says. "And I'm so glad I did."

It was Mary Geroux, an NP at the clinic, who saw the lump on Southward's neck that was pushing on an artery. Geroux linked Southward with a specialist and, last spring, she had the benign lump surgically removed. She's healthy now, and so is her faith in the health-care system.

In February, Premier Dalton McGuinty announced three additional NP-led clinics similar to Sudbury's will open in Belle River, Sault Ste. Marie and Thunder Bay. And in June, the government announced plans to fund eight more as it works toward its commitment to open a total of 25 in the province.

Nurse practitioners - also known as RNs in the Extended Class (EC) - have advanced education to diagnose and treat common illnesses and injuries, prescribe medications, and order diagnostic tests. Although the role in Canada is more than 40 years old, it wasn't legally recognized in Ontario until 1998. In addition to the clinics, McGuinty also announced proposed changes this spring to legislation that will expand NPs' practice by allowing them to set fractures and order MRIs and a wider range of diagnostic ultrasounds.

Nurse practitioners work everywhere from NP-led clinics to family health teams, community health centres, and as partners in innovative hospital and long-term care programs. And although they welcomed the Premier's recent announcements Tina Hurlock-Chorostecki, president of the Nurse Practitioners' Association of Ontario (NPAO), says legislative changes could do more, especially when it comes to the list of medications NPs can - and cannot - prescribe. This list is one of the biggest restrictions on practice, she says, adding that NPs should be able to write prescriptions - without a physician's signature - for medications they're knowledgeable about, and that they know their patients will benefit from.

"NPs have been educated, they have the scope of practice," Hurlock-Chorostecki says. In fact, in much of the U.S. and parts of Canada nurse practitioners can prescribe without any restrictions. Ontario is lagging behind in this regard and change is vital, not only to the legislation, but also to the Public Hospitals Act.

An adult NP on a transitional care unit (TCU) at London's St. Joseph's Health Care, Hurlock-Chorostecki fills a critical gap in the system. She treats people, including many elderly, who no longer need an acute care bed, but aren't yet well enough to go home or to long-term care. The Public Hospitals Act allows NPs to admit, treat and discharge patients in out-patient areas but not on in-patient units like the TCU. Although Hurlock-Chorostecki assesses which patients may benefit from a stay on the unit, and writes admission orders, she can only do so through a medical directive, a document that outlines specific actions NPs can perform under specific circumstances. These documents, signed by physicians, can take years to update. Hurlock-Chorostecki says she would be more effective if she could rely on her own knowledge instead of taking direction from a physician, who isn't al-ways available.

Nola Tremblay also believes NPs need to be able to practise to their full potential instead of within the limitations of legislation. "It's not proactive", she says of the list of drugs NPs can prescribe. By the time it's updated, "…our evidence has changed and it's no longer current".

Tremblay has spent the last nine years easing the burden for people who need care but whose illnesses have left them homebound. The North Bay primary health care nurse practitioner makes house calls as part of a program for frail elderly at the North-East Community Care Access Centre. If she thinks someone like Sophie*, a 76-year-old client who finds it difficult just to walk around her apartment, will benefit from a visit with a physiotherapist or dietitian, she makes sure that happens.

"We have an acute-care system, and elderly clients have a lot of chronic illnesses that don't fit into the acute care model," Tremblay says. Sophie may not be well-versed in the minute details of an NP's scope of practice, but she knows nurse practitioners have made a world of difference in her care. Tremblay helps her keep her prescriptions up-to-date and provides regular check-ups. "I love it because I don't have to go to the doctor's office", she says. "If I didn't have Nola (Tremblay), I don't know what I'd do."