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Canadian Journal of Nursing Leadership
Leadership in Nursing Management, Practice, Education & Research
Nursing
Leadership
www.nursingleadership.net
Advanced Practice Nursing in Canada:
Overview of a Decision Support Synthesis
A Historical Overview of the Development of Advanced Practice
Nursing Roles in Canada
Education of Advanced Practice Nurses in Canada
The Primary Healthcare Nurse Practitioner Role in Canada
The Acute Care Nurse Practitioner Role in Canada
The Clinical Nurse Specialist Role in Canada
The Role of Nursing Leadership in Integrating Clinical Nurse
Specialists and Nurse Practitioners in Healthcare Delivery in Canada
Clinical Nurse Specialists and Nurse Practitioners:
Title Confusion and Lack of Role Clarity
Factors Enabling Advanced Practice Nursing Role
Integration in Canada
Utilization of Nurse Practitioners to Increase Patient Access to
Primary Healthcare in Canada Thinking Outside the Box
Politics Policy Theory Innovation
Volume 23 Special Issue December 2010
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EDITORIAL 1
From the Guest Editor
Special Issue On Advanced Practice Nursing In Canada
As an innovation evolves, it reaches a point when there is enough experience
among enough informed people to step back and reflect broadly on the progress
made and seek views on its progress from those who have been instrumental in it.
Questions to be asked include where has adoption of the innovation been robust,
and where is it lagging or absent; what challenges have been encountered and
overcome, and where have forces been strong enough to forestall further develop-
ment; what is the potential for increased adoption of the innovation, or where is a
loss of momentum likely, and how may these trajectories play out? Furthermore, it
is important to seek explanations for the various outcomes that have resulted.
Advanced practice nursing in Canada is at this point. Nurse practitioners (NPs)
in Canada, including primary healthcare NPs, acute care NPs and a blended CNS/
NP role, have been in the healthcare environment for more than 40 years; clinical
nurse specialists (CNSs) for only slightly less time. Their evolutionary paths have
been different and been influenced by different forces, and they are facing quite
different challenges in the twenty-first century. Now is the right time to step back
and get answers to important questions about how these two types of nursing
practice are faring and why. This special issue does that.
Over the time that NPs and CNSs have been prepared and have practised in
Canada, considerable research has been undertaken to inform the current picture
of their status. When this research is combined with the experience of practition-
ers, policy makers and nursing leaders who have had direct experience with the two
roles, it is possible to provide a comprehensive, substantial and informed assess-
ment. For nurse practitioners, this is aided by data on the numbers of NPs across
each province provided by the Canadian Institute of Health Information. As well,
all provinces and territories have now passed legislation to regulate NP practice.
This is not true of CNSs, and one of the salient questions requiring exploration is,
why?
Dr. Alba DiCenso, who holds the CHSRF/CIHR Chair in Advanced Practice
Nursing at McMaster University, was the obvious choice to lead a team to under-
take this study. She has conducted more research on the topic of advanced practice
nursing than any other Canadian researcher. This has included evaluations of the
first neonatal nurse practitioner program in Canada and the Council of Ontario
2 Nursing Leadership Volume 23 Special Issue December 2010
University Consortium Program to prepare primary care nurse practitioners.
One of the objectives of her chair is to increase the number and expertise of
researchers in Canada to conduct high-quality and policy-relevant health serv-
ices research in the field of advanced practice nursing. The success of her capac-
ity building is reflected in the team of authors of this special issue, a team that
consists of senior and junior faculty, postdoctoral fellows, doctoral students and
staff affiliated with the Chair Program.
A core team of eight investigators (DiCenso, Martin-Misener, Donald, Bryant-
Lukosius, Kaasalainen, Kilpatrick, Carter and Harbman) was involved with all
components of the study, and one of this group took the lead in writing the article
for each component, describing the findings and discussion; however, the whole
team contributed to developing the outline for the article, reviewing and rewriting
elements, and editing it. The team for some sections was augmented by additional
individuals who had made specific contributions to that section. The contributing
authors are listed for each article.
The decision support
synthesis, which included a
scoping review, and inter-
views and focus groups
with decision makers and
practitioners across the
country, provided a rich reservoir of material on the historic and current status
of advanced practice nursing in Canada. The result is the most comprehensive
picture of the state of advanced practice nursing available to date. Readers may
approach this issue as a digest of the history and current status of advanced
practice nurses (APNs) in Canada and choose to read through all the articles.
Alternatively, they may selectively read articles of particular interest to them.
The issue begins with an overview paper (DiCenso) that provides a detailed
discussion of the rationale and objectives for the decision support synthesis and
details of the methods used in the scoping review, interviews and focus groups.
Each of the other nine articles provides a brief overview of the methods used
for that component of the study so that they can be read as standalone articles,
without reference to the overview article. The second article is a detailed descrip-
tion of the historical development of advanced practice nursing roles in Canada
(Kaasalainen). This is followed by an analysis of the education of APNs (Martin-
Misener), including the different provincial educational requirements, how the
education of APNs differs from CNSs, and the challenges confronting CNS prepa-
ration at this time.
Readers may approach this issue as a digest
of the history and current status of advanced
practice nurses (APNs) in Canada
3 From the Editor-in-Chief
The next three articles provide comprehensive analyses of the roles of the differ-
ent types of APNs the primary healthcare NP role (Donald), the acute care NP
role (Kilpatrick and Harbman) and the CNS role (Bryant-Lukosius). The last four
papers build on this background. Donald describes the differing ways in which
NPs and CNSs are treated in terms of such issues as title protection and the over-
lap in role competencies and the difficulties this creates for employers and policy
makers. The article on the role of leadership (Carter) describes the importance
of leaders in contributing to the success of both NPs and CNSs in fulfilling their
roles, including experiences of nurse leaders and the successful strategies they have
used. The article on enabling role integration of APNs (DiCenso) summarizes
factors found across all the study components that contribute to the integration of
both NPs and CNSs into the healthcare system at the national and local levels. The
final article (DiCenso) focuses on two examples NPs in fee-for-service practices
in British Columbia and NP-led practices in Ontario that demonstrate how NPs
have successfully expanded access to primary care.
All the papers in this special issue were peer reviewed and revised based on
the reviewers input. The reviewers represented a broad spectrum of Canadian
educators, administrators, researchers and policy advisors. We solicited commen-
taries for two articles: the education of APNs and the role of nursing leadership
in integrating APNs into the healthcare system. Both education and leadership
play critical roles in the preparation and implementation of advanced practice
roles. Dr. Cynthia Baker, the executive director of the Canadian Association of
Schools of Nursing and the former associate dean, nursing at Queens University,
wrote the commentary on education; and Pamela Hubley, a nurse practitioner
and the associate chief of nursing practice at The Hospital for Sick Children, an
organization that employs over 75 APNs, wrote the commentary on the role of
leadership.
The Office of Nursing Policy of the Strategic Policy Branch, Health Canada, the
Canadian Health Services Research Foundation (CHSRF) and the Canadian
Institutes of Health Research (CIHR), Knowledge Translation (KT) branch
co-funded this special issue. These organizations have been enormously support-
ive of the development of APNs and have played complementary roles in advanc-
ing their cause. The Office of Nursing Policy has funded studies, symposia and
meetings that allowed investigators, practitioners and administrators to sort
through and reach consensus on how to move the roles of APNs forward. CHSRF
has funded much of the research into APNs, and the KT branch of CIHR has
enthusiastically supported the translation of APN research into policy. The
Canadian Nurses Association (CNA) took the lead in developing the Advanced
Nursing Practice Framework and spearheaded the Canadian Nurse Practitioner
Initiative. Given this demonstrated commitment, we invited Rachel Bard, chief
executive officer of the CNA, and Sandra MacDonald-Rencz, Director of the
Office of Nursing Policy, to co-author the introduction to the issue, and Jennifer
Ellis and Erin Morrison of CHSRF to write an introduction to the overview article
by Alba DiCenso that leads off the issue.
CHSRFs vision is Timely, appropriate and high-quality services that improve
the health of all Canadians. There are a number of ways that CHSRF works to
realize this vision that are directly related to advanced practice nursing including
commissioning research and promoting dialogue on key healthcare policy issues,
and by gathering and sharing information about innovative and effective health-
care practices. The progress in research and health policy regarding the education
and deployment of APNs is an excellent example of CHSRFs goals being real-
ized. CHSRFs EXTRA (Executive Training for Research Application) program
is another way that advanced practice nursing can benefit by training leaders
including nurse leaders to use research to advocate for and introduce innovations
such as APNs into health care delivery. We would like to congratulate the team of
researchers who developed this special issue we believe it will make a valuable
contribution to the public dialogue on the role of advanced practice nursing
in Canada.

Dorothy Pringle, OC, RN, PhD, FCAHS
Editor, Special Issue
5
GUEST EDITOR
Dorothy Pringle, OC, RN, PhD, FCAHS
Professor Emeritus & Dean Emeritus
Lawrence S. Bloomberg Faculty of Nursing
University of Toronto
EDITOR-IN-CHIEF
Lynn M. Nagle, RN, PhD
Assistant Professor
Lawrence S. Bloomberg Faculty of Nursing
EDITOR, POLICY AND INNOVATION
Michael J. Villeneuve, RN, MSc
Scholar in Residence
Canadian Nurses Association
EDITOR, PRACTICE
Patricia Petryshen, RN, PhD
Vancouver/Toronto
EDITOR, RESEARCH
Greta G. Cummings RN, PhD
CIHR New Investigator
AHFMR Population Health Investigator
Professor, Faculty of Nursing,
University of Alberta
BOOK EDITOR
Gail J. Donner, RN, PhD
Partner, donnerwheeler
Professor Emeritus
Lawrence S. Bloomberg Faculty of Nursing,
EDITORIAL ADVISORY BOARD
Mary Ferguson-Par, RN, PhD (Chair)
Vice President Professional Affairs and Chief
Nurse Executive, University Health Network
Toronto, ON
Mary Ellen Gurnham, RN, MN
Chief Nursing Officer & Director of
Professional Practice Development
Capital District Health Authority
Halifax, NS
Wendy Hill, RN, MN
Assistant Deputy Minister of the Performance
Management and Improvement Division.
British Columbia Ministry of Health
Victoria, BC
Beverly Malone, PhD, RN, FAAN
Chief Executive Officer
National League for Nursing
New York, NY
Patricia OConnor, RN, MSc (A), CHE
Director of Nursing and CNO,
Montreal General Hospital
Rhonda Seidman-Carlson, RN, MN
Director, Professional Practice
Markham Stouffville Hospital
Joan Shaver, PhD, RN, FAAN
Dean, College of Nursing
University of Arizona
Tucson, Arizona
Linda Silas, RN, BScN,
President
Canadian Federation of Nurses Unions
Ottawa, ON
Carol A. Wong, RN, MScN, PhD
Assistant Professor
School of Nursing, Faculty of Health Sciences
The University of Western Ontario
London, ON
EDITORIAL DIRECTOR
Dianne Foster-Kent
COPYEDITOR
Francine Geraci
PROOFREADER
Scott Bryant
PUBLISHER
Anton Hart
ASSOCIATE PUBLISHER
Rebecca Hart
ASSOCIATE PUBLISHER
Susan Hale
ASSOCIATE PUBLISHER
Matthew Hart
ASSOCIATE PUBLISHER/ADMINISTRATION
Barbara Marshall
DESIGN AND PRODUCTION
Yvonne Koo
Jonathan Whitehead
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In This Issue
1 From the Guest Editor
INTRODUCTION
8 The Role for Advanced Practice Nursing in Canada
Sandra MacDonald-Rencz and Rachel Bard
COMMENTARY
12 Understanding Advanced Practice Nursing
Jennifer Ellis and Erin Morrison

15 Advanced Practice Nursing in Canada:
Overview of a Decision Support Synthesis
Alba DiCenso, Ruth Martin-Misener, Denise Bryant-Lukosius, Ivy Bourgeault,
Kelley Kilpatrick, Faith Donald, Sharon Kaasalainen, Patricia Harbman, Nancy Carter,
Sandra Kioke, Julia Abelson, R. James McKinlay, Dianna Pasic, Brandi Wasyluk,
Julie Vohra and Renee Charbonneau-Smith
35 A Historical Overview of the Development of Advanced Practice Nursing
Roles in Canada
Sharon Kaasalainen, Ruth Martin-Misener, Kelley Kilpatrick, Patricia Harbman,
Denise Bryant-Lukosius, Faith Donald, Nancy Carter and Alba DiCenso
61 Education of Advanced Practice Nurses in Canada
Ruth Martin-Misener, Denise Bryant-Lukosius, Patricia Harbman, Faith Donald,
Sharon Kaasalainen, Nancy Carter, Kelley Kilpatrick and Alba DiCenso
COMMENTARY
85 Advancing the Educational Agenda
Carolyn Baker
88 The Primary Healthcare Nurse Practitioner Role in Canada
Faith Donald, Ruth Martin-Misener, Denise Bryant-Lukosius, Kelley Kilpatrick,
Sharon Kaasalainen, Nancy Carter, Patricia Harbman, Ivy Bourgeault and
Alba DiCenso
114 The Acute Care Nurse Practitioner Role in Canada
Kelley Kilpatrick, Patricia Harbman, Nancy Carter, Ruth Martin-Misener,
Denise Bryant-Lukosius, Faith Donald, Sharon Kaasalainen, Ivy Bourgeault
and Alba DiCenso
140 The Clinical Nurse Specialist Role in Canada
Denise Bryant-Lukosius, Nancy Carter, Kelley Kilpatrick, Ruth Martin-Misener,
Faith Donald, Sharon Kaasalainen, Patricia Harbman, Ivy Bourgeault and
Alba DiCenso
In This Issue
Published by the Academy of Canadian Executive Nurses/L'Acadmie des
Chefs de Direction en Soins Infirmiers and Longwoods Publishing Corporation
7
167 The Role of Nursing Leadership in Integrating Clinical Nurse Specialists
and Nurse Practitioners in Healthcare Delivery in Canada
Nancy Carter, Ruth Martin-Misener, Kelley Kilpatrick, Sharon Kaasalainen,
Faith Donald, Denise Bryant-Lukosius, Patricia Harbman, Ivy Bourgeault and
Alba DiCenso
COMMENTARY
186 Close to the Tipping Point
Pam Hubley
189 Clinical Nurse Specialists and Nurse Practitioners:
Title Confusion and Lack of Role Clarity
Faith Donald, Denise Bryant-Lukosius, Ruth Martin-Misener, Sharon Kaasalainen,
Kelley Kilpatrick, Nancy Carter, Patricia Harbman, Ivy Bourgeault and Alba DiCenso
211 Factors Enabling Advanced Practice Nursing Role Integration in Canada
Alba DiCenso, Denise Bryant-Lukosius, Ruth Martin-Misener, Faith Donald,
Julia Abelson, Ivy Bourgeault, Kelley Kilpatrick, Nancy Carter, Sharon Kaasalainen
and Patricia Harbman
239 Utilization of Nurse Practitioners to Increase Patient Access to
Primary Healthcare in Canada Thinking Outside the Box
Alba DiCenso, Ivy Bourgeault, Julia Abelson, Ruth Martin-Misener, Sharon
Kaasalainen, Nancy Carter, Patricia Harbman, Faith Donald, Denise Bryant-Lukosius
and Kelley Kilpatrick
Indicates Peer-review
8
The Role for Advanced Practice Nursing
in Canada
Sandra MacDonald-Rencz, Executive Director, Office of Nursing Policy, Strategic Policy
Branch, Health Canada
Rachel Bard, RN, MA Ed, Chief Executive Officer, Canadian Nurses Association
INTRODUCTION
The delivery of modern health services is a complex activity that increasingly relies
on inter-professional collaboration. The different roles of the members of these
inter-professional teams may depend not only on traditional job demarcations but
also on a division of labour that maximizes efficiency and improves outcomes.
Canadian health policy makers and healthcare managers are continually seeking
opportunities to optimize healthcare delivery by modernizing the roles and mix of
health professionals, including nurses. Innovations in care are being implemented
in response to growing healthcare demands (driven by a rising prevalence of
chronic diseases), limited access to physicians (in general or in certain specialties
or geographic areas) and tight budget constraints. In addition, in countries where
the supply of nurses itself may be an issue, the development of more advanced
practice roles may be seen as a way to increase recruitment and retention rates by
enhancing career prospects in the profession.
In Canada, discussions about possible extensions of the roles of nurses have
taken place in the context of broader efforts to reorganize health service delivery,
particularly in the primary care sector and in the development of home- and
community-based care options. Two categories of advanced nursing practice roles
have emerged to address these needs: nurse practitioners (NPs) and clinical nurse
specialists (CNSs). Many NPs practise in primary care, acting as the first contact
for people with minor illness, providing routine follow-up for patients with
chronic conditions, prescribing drugs and/or ordering tests. Other NPs practise
in acute care settings in hospitals or in specialized outpatient settings to provide
advanced nursing care for patients who are acutely, critically or chronically ill with
complex conditions. CNSs tend to work in hospitals, where their responsibilities
include conducting research and providing leadership and education to the nurs-
ing staff to promote high standards of care and patient safety.
A recently published Organisation for Economic Co-operation and Development
report cites Canada and the United States as world leaders in the implementa-
tion of advanced practice roles (Delamaire and Lafortune 2010). Canada has been
experimenting with and implementing new advanced nursing practice roles for
many decades. In the United States, the introduction of NPs, who are responsible
for delivering a wide range of services with a high level of autonomy, dates back to
the mid-1960s. In many European countries, the development of advanced nurs-
ing practice roles is still in its infancy, although some countries, such as France,
have recently launched a series of pilot projects to test new models of teamwork
between doctors and nurses in primary care and chronic disease management.
Research investments to date have identified key areas of action to further the
implementation of advanced practice roles. Progress has also been made in
providing a framework that delineates whether an advanced nursing practice role
is appropriate in given circumstances. Other research on NP practice tells us how
positive the health outcomes are, but it does not provide enough economic analy-
sis. We know even less about the impact of CNS practice in Canada. More research
that clarifies the true impact of advanced practice can assist the health system as
decision makers grapple with financial constraints and seek to maximize value for
money. Disseminating the results of such research is no less important.
A number of very promising innovations in care are being driven by advanced
practice nurses in intervening with high-acuity patients who require the coordi-
nated actions of a number of specialized professionals in areas such as neonatol-
ogy and cardiology. We are seeing a growing number of examples where NP
physician collaboration in primary care (in both NP-led clinics and fee-for-service
physician practice) has significantly lowered wait times and improved patient
access to care. We are also seeing that, with anticipated changes in the nursing
workforce, and as CNSs collaborate with and lead inter-professional teams,
the role of the CNS is becoming even more critical for supporting nurses and
providing clinical expertise. As the adoption of healthcare models based on
inter-professional collaboration becomes more widespread, there exists a unique
opportunity to identify niches that can best be filled by advanced practice nurses.
The evolution of advanced practice has had as much to do with enhancing
patient-centred care as it has with the expertise required to remain at the cutting
edge of clinical and technological advancements. Clinical leadership, support
for nursing staff and the advancement of research coalesce to produce synergies
leading to better outcomes and enhanced patient experiences. As we increase our
ability to capture metrics, particularly financial indicators, on the tangible benefits
of advanced practice, we will likely see more opportunities created. However, the
great variability in CNS specialties makes it more difficult to capture data relevant
to these roles.
The papers presented in this issue do an excellent job of identifying and consoli-
dating the various factors that have both enabled and impeded the development
and integration of advanced nursing practice in Canada. It is clear from the
research that a collaborative approach is needed to implement the recommenda-
tions, address outstanding issues, and help build the necessary infrastructure and
networks to support nurses working in advanced practice roles. Many of the iden-
tified challenges arise from variations in educational requirements and programs,
credentialling, legislation and regulation. The continued collaboration among
educators, regulatory bodies, policy makers and governments will, undoubtedly,
work to address these inconsistencies.
To this end, professional nursing organizations, regulators, educators and
researchers have worked with federal, provincial and territorial governments and
with research agencies to develop pan-Canadian measures for integrating the
NP role in primary care. The Canadian Nurse Practitioner Initiative, supported
through the Primary Health Care Transition Fund between 2004 and 2006, has
been particularly successful in this regard.
It is also important for nursing leaders to continue to introduce advanced practice
nursing roles that align with current and emerging population health and system
needs, and to ensure that these roles meet the criteria developed through broader
national frameworks.
The key to the future of the healthcare system lies in successfully integrating
health professionals into teams that are cohesive, high-performing units. As
colleagues and leaders, we join the authors in stressing the importance of all
professional groups working together to develop innovative models of care that
can address current and emerging healthcare gaps. We encourage you to learn
from the papers, which bring new insights into advanced nursing practice in
Canada. This information is especially valuable given that much of the unreal-
ized potential surrounding advanced practice can be linked to a lack of clarity in
role definition and implementation. Without such research, the development of
advanced practice roles would likely continue to experience growing pains and fall
short of the tremendous benefits that could be realized.
Despite the many challenges, the future of advanced nursing practice shows great
promise. We will fulfill this potential if we, as nursing leaders, increasingly act in
concert to promote clarity and consistency in our collective approach to address-
ing remaining barriers. Better development and integration of advanced practice
roles are crucial to realizing the full contribution of nursing to sustainable, acces-
sible, quality healthcare in Canada.
Reference
Delamaire, M-L and G. Lafortune. 2010. Nurses in Advanced Roles: A Description and Evaluation of
Experiences in 12 Developed Countries. OECD Health Working Paper No. 54. Retrieved July 12, 2010.
<www.oecd.org/els/health/workingpapers>.
12
The Canadian Health Services Research Foundation (CHSRF) is proud to be one of
the supporters of this special issue on advanced practice nursing, which represents
several decades of research and programming related to the role of nurses in the
health system.
Advanced practice nursing has long been a poorly understood area of health serv-
ices delivery. It is telling that the most popular issue in CHRSFs Mythbusters series
is Myth: Seeing a Nurse Practitioner instead of a Doctor Is Second-Class Care, first
published in 2002 and then updated and re-released in 2010 (CHRSF 2010).
Advanced practice nursing has existed in Canada since the 1960s, when nurse
practitioners (NPs) were introduced mainly to address shortages of primary care
physicians in rural and remote areas. But it is only since the beginning of the
twenty-first century that we have seen substantial growth in NP numbers the
NP workforce in Canada doubled from 800 in 2004 to 1,626 in 2008. APNs now
work in a wide range of primary and acute care settings. A 2009 Harris/Decima
poll of 1,000 Canadians found that 20% had been treated by an NP, more than
75% would be comfortable seeing an NP instead of their family doctor, and 80%
thought expanded use of NPs could help control health costs. On the other hand,
while NP numbers have been increasing, the opposite has been occurring in the
numbers of clinical nurse specialists (CNSs), which, according to a 2010 Canadian
Institute for Health Information report (CIHI 2010), dropped from 2,624 to
2,222, a total of 402, between 2000 and 2008.
COMMENTARY
Understanding Advanced Practice
Nursing
Jennifer Ellis, RN, PhD
Policy Director
Canadian Health Services Research Foundation,
Ottawa, ON
Erin Morrison, RN, MHSA
Senior Advisor, Regional Capacity Development
Canadian Health Services Research Foundation,
Ottawa, ON
13 Understanding Advanced Practice Nursing
Over the past 10 years, advanced practice nursing has been transformed from
a field with sparse research and literature to one with an increasing body of
evidence to demonstrate its valuable role. CHSRF has contributed to this evolu-
tion through instruments such as the Chair Program in Advanced Practice
Nursing. Researchers have also been able to call on resources through the $25
million Nursing Research Fund, granted by Health Canada and administered by
CHSRF. Clinical Nurse Specialists and Nurse Practitioners in Canada: A Decision
Support Synthesis the report that inspired this special issue was funded through
CHSRF in partnership with Health Canadas Office of Nursing Policy.
Thanks to the work of Dr. Alba DiCenso and Dr. Denise Bryant-Lukosius, and
with the support of a strong research team, that report synthesizes an exhaus-
tive body of evidence and culminates with a series of recommendations reached
through consultation with decision and policy makers such as professional asso-
ciations, employers and governments (DiCenso et al. 2010).
Advanced practice nurses (APNs) are starting to make major breakthroughs
across Canada; for example, in British Columbia, NPs are being integrated into
traditional fee-for-service practices, and Ontario plans to open 26 NP-led clinics
across the province by the end of 2012. The growing trend toward use of interdis-
ciplinary teams in primary healthcare in most provinces is also opening the door
to more NPs. Projects like this special issue and the decision support synthesis are
essential to broaden understanding of NPs and CNSs potential. Bryant-Lukosius
et al. (2010) highlight the opportunities for greater expansion of the CNS role in
long-term care facilities.
The decision support synthesis contained a number of recommendations to
advance the role of APNs in Canada, including standardizing APN regulatory
and educational requirements and expanding training on interprofessionalism
in health professional education programs. Another recommendation was that a
pan-Canadian mutlidisciplinary task force involving key stakeholder groups be
established to facilitate the implementation of advanced practice nursing roles.
We sincerely hope that this special issue, along with the decision support synthesis,
will help to provide the information needed to encourage health services leaders
across Canada to effectively integrate advanced practice nursing into their health
human resource planning. However, one important area where research is still
lacking is a solid economic analysis of the cost-effectiveness of the role of APNs.
CHSRFs vision is Timely, appropriate and high-quality services that improve
the health of all Canadians. The progress in research and health policy regard-
ing the education and deployment of APNs is an excellent example of CHSRFs
vision being realized. We would like to congratulate the team of researchers who
developed this special issue we believe it will make a valuable contribution to the
public dialogue on the role of advanced practice nursing in Canada.
References
Bryant-Lukosius, D., N. Carter, K. Kilpatrick, R. Martin-Misener, F. Donald, S. Kaasalainen, P.
Harbman, I. Bourgeault and A. DiCenso. 2010. The Clinical Nurse Specialist Role in Canada.
Canadian Journal of Nursing Leadership 23(Special Issue December): 14066.
Canadian Health Services Research Foundation. 2010. Myth: Seeing a Nurse Practitioner instead of a
Doctor Is Second-Class Care. Ottawa, ON: CHSRF. Retrieved November 15, 2010. <http://www.chsrf.
ca/Migrated/PDF/Mythbusters/mythbusters_APN_en_FINAL.pdf>.
Canadian Institute for Health Information. 2010. Regulated Nurses: Canadian Trends, 2004-2008.
Updated February 2010. Ottawa, ON: CIHI. Retrieved November 15, 2010. <http://secure.cihi.ca/
cihiweb/products/regulated_nurses_2004_2008_en.pdf>
Canadian Nurses Association. 2006. 2005 Workforce Profile of Registered Nurses in Canada. Ottawa,
ON: CNA. Retrieved March 2, 2009. <http://www.cna-nurses.ca/CNA/documents/pdf/publications/
workforce-profile-2005-e.pdf>.
DiCenso, A., D. Bryant-Lukosius, I. Bourgeault, R. Martin-Misener, F. Donald, J. Abelson, S.
Kaasalainen, K. Kilpatrick, S. Kioke, N. Carter and P. Harbman. 2010. Clinical Nurse Specialists and
Nurse Practitioners in Canada: A Decision Support Synthesis. Retrieved November 15, 2010. <http://
www.chsrf.ca/migrated/pdf/10-CHSRF-0362_Dicenso_EN_Final. pdf>.
15
ADVANCED PRACTICE NURSING
Advanced Practice Nursing in
Canada: Overview of a Decision
Support Synthesis
Alba DiCenso, RN, PhD
CHSRF/CIHR Chair in Advanced Practice Nursing (APN)
Director, Ontario Training Centre in Health Services & Policy Research
Professor, Nursing and Clinical Epidemiology & Biostatistics, McMaster University
Hamilton, ON
Ruth Martin-Misener, NP, PhD
Associate Professor & Associate Director, Graduate Programs, School of Nursing,
Dalhousie University
Halifax, NS
Affiliate Faculty, CHSRF/CIHR Chair Program in APN
Denise Bryant-Lukosius, RN, PhD
Assistant Professor, School of Nursing & Department of Oncology, McMaster University
Senior Scientist, CHSRF/CIHR Chair Program in APN
Director, Canadian Centre of Excellence in Oncology Advanced Practice Nursing (OAPN) at
the Juravinski Cancer Centre
Hamilton, ON
Ivy Bourgeault, PhD
CIHR/Health Canada Research Chair in Health Human Resource Policy
Scientific Director, Population Health Improvement Research Network and Ontario Health
Human Resources Research Network
Professor, Interdisciplinary School of Health Sciences, University of Ottawa
Ottawa, ON
Kelley Kilpatrick, RN, PhD
Postdoctoral Fellow, CHSRF/CIHR Chair Program in APN
Professor, Department of Nursing, Universit du Qubec en Outaouais
St-Jrme, QC
Faith Donald, NP-PHC, PhD
Associate Professor, Daphne Cockwell School of Nursing, Ryerson University
Toronto, ON
Sharon Kaasalainen, RN, PhD
Associate Professor, School of Nursing, McMaster University
Career Scientist, Ontario Ministry of Health and Long-Term Care
Hamilton, ON
Patricia Harbman, NP-PHC, MN/ACNP Certificate, PhD(c), University of Toronto
Graduate student in CHSRF/CIHR Chair Program in APN
Oakville, ON
Nancy Carter, RN, PhD
CHSRF Postdoctoral Fellow
Junior Faculty, CHSRF/CIHR Chair Program in APN, McMaster University
Hamilton, ON
Sandra Kioke, RN, PhD student, University of Victoria
Courtenay, BC
Julia Abelson, PhD
Professor, Clinical Epidemiology & Biostatistics, McMaster University
Director, Centre for Health Economics & Policy Analysis (CHEPA)
Hamilton, ON
R. James McKinlay, BPhEd
Research Coordinator, CHSRF/CIHR Chair Program in APN, McMaster University
Hamilton, ON
Dianna Pasic, BAH (Psychology)
Senior Research Coordinator, Centre for Health Economics and Policy Analysis (CHEPA)
McMaster University
Hamilton, ON
Brandi Wasyluk, BSc
Research Assistant, CHSRF/CIHR Chair Program in APN, McMaster University
Hamilton, ON
Julie Vohra, MSc
Program Coordinator, CHSRF/CIHR Chair Program in APN, McMaster University
Hamilton, ON
Renee Charbonneau-Smith, RN, MSc
Knowledge Exchange Specialist, CHSRF/CIHR Chair Program in APN, McMaster University
Hamilton, ON
17 Advanced Practice Nursing in Canada: Overview of a Decision Support Synthesis
Introduction
Nurse practitioners (NPs) and clinical nurse specialists (CNSs) have existed in
Canada for about four decades. Both are considered advanced practice nurses
(APNs), defined internationally as registered nurses (RNs) who have acquired the
expert knowledge base, complex decision-making skills and clinical competencies
for expanded practice (International Council of Nurses 2008). Advanced nursing
practice, according to the national framework developed by the Canadian Nurses
Association (CNA), is
an umbrella term describing an advanced level of clinical nursing prac-
tice that maximizes the use of graduate educational preparation, in-depth
Abstract
The objective of this decision support synthesis was to identify and review published
and grey literature and to conduct stakeholder interviews to (1) describe the distin-
guishing characteristics of clinical nurse specialist (CNS) and nurse practitioner (NP)
role definitions and competencies relevant to Canadian contexts, (2) identify the key
barriers and facilitators for the effective development and utilization of CNS and NP
roles and (3) inform the development of evidence-based recommendations for the
individual, organizational and system supports required to better integrate CNS and
NP roles into the Canadian healthcare system and advance the delivery of nursing
and patient care services in Canada. Four types of advanced practice nurses (APNs)
were the focus: CNSs, primary healthcare nurse practitioners (PHCNPs), acute care
nurse practitioners (ACNPs) and a blended CNS/NP role.
We worked with a multidisciplinary, multijurisdictional advisory board that helped
identify documents and key informant interviewees, develop interview ques-
tions and formulate implications from our findings. We included 468 published
and unpublished English- and French-language papers in a scoping review of the
literature. We conducted interviews in English and French with 62 Canadian and
international key informants (APNs, healthcare administrators, policy makers, nurs-
ing regulators, educators, physicians and other team members). We conducted four
focus groups with a total of 19 APNs, educators, administrators and policy makers.
A multidisciplinary roundtable convened by the Canadian Health Services Research
Foundation formulated evidence-informed policy and practice recommendations
based on the synthesis findings.
This paper forms the foundation for this special issue, which contains 10 papers
summarizing different dimensions of our synthesis. Here, we summarize the synthe-
sis methods and the recommendations formulated at the roundtable.
nursing knowledge and expertise in meeting the health needs of individu-
als, families, groups, communities and populations. It involves analyzing
and synthesizing knowledge; understanding, interpreting and applying
nursing theory and research; and developing and advancing nursing
knowledge and the profession as a whole (CNA 2008: 10).
Core advanced practice nursing roles include direct patient care, research, educa-
tion, consultation, collaboration and leadership activities.
Despite the 40-year existence of APNs, the implementation of their roles in
Canada has been sporadic and dependent on the changing political agendas
shaping the healthcare system. Given the instability of the roles, the Office of
Nursing Policy of Health Canada and the Canadian Health Services Research
Foundation (CHSRF) commissioned a decision support synthesis. It aimed to
develop evidence-informed policy and practice recommendations for optimizing
the contributions of NPs and CNSs in meeting Canadians healthcare needs. A
decision support synthesis seeks to address a policy-relevant question through a
deliberative process involving the engagement of decision makers, distillation of
published and grey literature, data collection from key stakeholders and, finally,
integration and analysis of the data to develop policy and management recom-
mendations (CHSRF 2010).
This special issue of the Canadian Journal of Nursing Leadership focuses entirely
on the synthesis, beginning with this paper, which summarizes the methods and
resulting recommendations. The following nine papers focus on various dimen-
sions of the APN role in Canada. They include a historical account (Kaasalainen
et al. 2010), an examination of educational issues (Martin-Misener et al. 2010),
detailed summaries of the status of primary healthcare NPs (Donald et al. 2010b),
acute care NPs (Kilpatrick et al. 2010) and CNSs (Bryant-Lukosius et al. 2010), the
role of nursing leadership in integrating APN roles (Carter et al. 2010), an exami-
nation of title confusion and lack of role clarity as barriers to role implementation
(Donald et al. 2010a), factors enabling role integration (DiCenso et al. 2010c) and,
finally, examples of innovative models that utilize NPs to increase patient access to
primary healthcare (DiCenso et al. 2010a).
Types of APNs
In Canada, APNs include primary healthcare NPs (PHCNPs), acute care NPs
(ACNPs), CNSs and CNS/NPs (a blended role). The nurse anesthetist role is just
emerging and was not addressed in this synthesis. NPs are
registered nurses with additional educational preparation and experi-
ence who possess and demonstrate the competencies to autonomously
diagnose, order and interpret diagnostic tests, prescribe pharmaceuticals
and perform specific procedures within their legislated scope of practice
(CNA 2009b: 1).
PHCNPs, also known as family or all-ages NPs, typically work in the community
in settings such as community health centres, primary healthcare teams and long-
term care. Their main focus is health promotion, preventive care, diagnosis and
treatment of acute minor illnesses and injuries, and monitoring and management
of stable chronic diseases. ACNPs, also known as specialty or specialist NPs as well
as adult, pediatric and neonatal NPs, provide advanced nursing care across the
continuum of acute care services for patients who are acutely, critically or chroni-
cally ill, often with multiple and complex morbidities. These ACNPs might work
in settings such as neonatology, nephrology and cardiology. Titling of NP roles
is in transition. For the purposes of our synthesis, we refer to NPs who practise
in community settings with a focus on families and all ages as PHCNPs. We refer
to those who work in hospital in-patient or ambulatory settings with a focus on
specialized populations as ACNPs.
CNSs are RNs with a graduate degree in nursing who have expertise in a clinical
nursing specialty and perform a role that includes practice, consultation, collabo-
ration, education, research and leadership. They contribute to the development of
nursing knowledge and evidence-based practice and address complex healthcare
issues for patients, families, other disciplines, administrators and policy makers
(CNA 2009a). CNSs specialize in a specific area of practice that may be defined in
terms of a population, setting, disease or medical subspecialty, type of care or type
of problem.
There are also APNs who combine the CNS and NP roles (Pinelli 1997). The
blended CNS/NP role was first introduced in Ontario in tertiary-level neonatal
intensive care units (NICUs) in the late 1980s (Hunsberger et al. 1992). At the
time, the blended CNS/NP title was chosen to protect time for the nonclinical
dimensions of advanced practice. However, current CNS/NP practice is consistent
with the ACNP role involving the clinical care of complex medical problems and
patient care planning and coordination, in addition to leadership, consultation and
research. Given that nonclinical role dimensions have been proposed as essential
components of all advanced practice nursing roles, there is no longer a need for a
separately titled CNS/NP role, and most of these APNs now are known as ACNPs.
Numbers of APNs in Canada
Between 2004 and 2008, the number of licensed NPs in Canada more than
doubled, increasing from 800 to 1,626 (Canadian Institute for Health Information
[CIHI] 2010). This figure, however, is an underestimate of the NP workforce as the
numbers do not include ACNPs from all Canadian jurisdictions. Until recently,
in some provinces ACNPs have not been licensed, and therefore it is not currently
possible to determine how many exist in Canada. It is also difficult to ascertain the
exact number of CNSs in Canada because there is no protected titling or standard
credentialling mechanism. Based on self-reported CNS data, the number of CNSs
decreased between 2000 and 2008 from 2,624 to 2,222, accounting for about 1% of
the Canadian nursing workforce (CIHI 2010; CNA 2006).
Effectiveness of APNs
There is abundant research demonstrating the safety and effectiveness of
PHCNPs, ACNPs and CNSs. In preparation for our decision support synthesis, we
conducted searches for all randomized controlled trials ever published interna-
tionally comparing APNs to usual care in terms of patient, provider and/or health
system outcomes. While our search was not as comprehensive as one would do
for a formal systematic review, we found a total of 78 trials: 28 of PHCNPs, 17 of
ACNPs, 32 of CNSs and one of CNS/NPs. Findings consistently showed that care
by APNs resulted in equivalent or improved outcomes. The complete listing of
studies and their findings is included in an appendix to our full decision support
synthesis report, found on the CHSRF website (DiCenso et al. 2010b).
A systematic review of NPs in primary care found that patients receiving NP care
had higher satisfaction and better quality of care than those receiving physician
care, with no difference in health outcomes (Horrocks et al. 2002). A recent study
of four primary healthcare delivery models in Ontario found high-quality chronic
disease management was associated with the presence of a PHCNP (Russell et al.
2009). Comparisons of ACNP care with usual care showed either no differences in
outcomes such as mortality, morbidity/complications and length of hospital stay
or an improvement in outcomes favouring the ACNP role (e.g., Dawes et al. 2007;
Krichbaum 2007).
In their annotated bibliography of 70 studies, Fulton and Baldwin (2004) found
that CNSs were associated with reductions in hospital length of stay, readmissions,
emergency room visits and costs, as well as improvements in staff nurse knowl-
edge, functional performance, mood state, quality of life and patient satisfaction.
Mitchell-DiCenso et al. (1996) found that CNS/NPs functioning in the blended
role in NICUs were equivalent to pediatric residents with respect to neonatal
morbidity and mortality, parent satisfaction, costs and incidence of long-term
developmental delays.
Synthesis Objective
The objective of this decision support synthesis was to identify and review
published and grey literature and to conduct stakeholder interviews to
(1) describe the distinguishing characteristics of CNS and NP role definitions
and competencies relevant to Canadian contexts, (2) identify the key barriers and
facilitators for the effective development and utilization of CNS and NP roles and
(3) inform the development of evidence-based recommendations for the individ-
ual, organizational and health system supports required to better integrate CNS
and NP roles into the Canadian healthcare system and advance the delivery of
nursing and patient care services in Canada. In this paper, we outline the detailed
methods of our synthesis that form the foundation for the papers that follow in
this special issue.
Methods
We received ethics approval from the McMaster University Research Ethics Board
on July 15, 2008. The synthesis included a number of elements: (1) an advisory
board, (2) a scoping review of the literature, (3) key informant interviews and
focus groups and (4) a multidisciplinary roundtable to formulate recommenda-
tions from the synthesis findings. Each of these elements is described below.
Advisory Board
We formed a 23-member multidisciplinary (administrators, policy makers, prac-
titioners, educators, regulators and researchers) and multijurisdictional (interna-
tional, federal, provincial and territorial) advisory board. Via teleconferences and
an all-day face-to-face meeting, advisory board members helped identify relevant
documents and key informant interviewees, develop interview questions and
formulate implications based on the findings.
Scoping Review of the Literature
We conducted a scoping review using established methods (Arksey and OMalley
2005; Anderson et al. 2008) to summarize the literature on advanced practice
nursing role definitions, competencies and utilization in the Canadian healthcare
system, identify the policies influencing the development and integration of these
roles and explore the gaps and opportunities for their improved deployment.
Like systematic reviews, scoping reviews use rigorous and transparent methods
to comprehensively search for all relevant literature and to analyze and interpret
the data. However, a scoping review differs from a systematic review in three ways.
First, a scoping review is exploratory in nature and seeks to map all the relevant
literature on a broad topic and identify recurring themes, while a systematic
review addresses a highly specific research question and focuses strictly on empiri-
cal studies. Second, in a scoping review, the criteria for exclusion and inclusion are
based not on the quality of the studies, but on relevance. Because scoping reviews
are exploratory, all papers on a topic are included, be they studies or narrative
and commentary pieces such as editorials and essays. Third, all information from
the included papers is charted, and themes and key issues are identified. Because
of the broad inclusion criteria, many themes emerge that can inform gaps in the
existing research.
We concentrated on Canadian literature of all types to capture context-free,
context-sensitive and colloquial evidence (CHSRF 2010). In keeping with the tenets
of scoping reviews, we did not exclude articles based on methodological quality.
To guide our work, we developed a framework to capture the structure, proc-
ess and outcome dimensions and descriptors of advanced practice nursing roles.
Structure-related dimensions included role description, numbers, types, education,
competencies, regulation, scope of practice, practice settings, union membership
and liability coverage. Process-related dimensions included barriers and facilita-
tors associated with role implementation and practice patterns. Outcome-related
dimensions included patient, provider and health system outcomes.
We searched MEDLINE, CINAHL and EMBASE using applicable Mesh headings
and free text keywords pertinent to CNSs, NPs and CNS/NPs, and we performed
a citation search using the Web of Science database and 10 key papers that directly
addressed structure, process and outcome dimensions of advanced practice
nursing roles. We scanned the reference lists of all relevant papers and searched
websites of Canadian professional organizations and national, provincial and
territorial governments. The four journals yielding the greatest number of rele-
vant articles, Canadian Journal of Nursing Leadership, Journal of Advanced Nursing,
Canadian Nurse and Clinical Nurse Specialist, were hand searched from May 2008
to January 2009 to avoid omitting papers published after the original database
search. Advisory board and research team members contributed relevant papers
from their personal files.
Papers included in the synthesis met the following criteria:
All Canadian papers including primary studies, literature and policy reviews,
reports, editorials, essays, commentaries and descriptive accounts (any date of
publication)
International review papers published between 2003 and 2008
International non-review papers only if of unique relevance to the synthesis or
if little Canadian literature existed on the topic
Written in French or English
Addressing structure, process and/or outcome dimensions of one or more
advanced practice nursing roles
The search yielded 2,397 papers (Figure 1). They were divided among three teams
of two researchers for title and abstract review (researchers had participated in
training to ensure consistency across reviews). We resolved within-team disagree-
ments by having a third team member review the disputed titles and abstracts.
If a paper was deemed relevant after title and abstract review, one team member
reviewed the full text, using our inclusion criteria. We identified 573 relevant papers
for data extraction. The team was divided into triads, and each triad reviewed and
extracted data from literature pertinent to a specific advanced practice nursing role
(e.g., CNSs). During this stage, 105 papers failed to meet our inclusion criteria,
leaving 468 papers in the synthesis. Figure 2 summarizes the country of origin of
the 468 papers. They represent all Canadian papers but only recent reviews from
other countries, hence the large proportion of Canadian papers (69%). Figure 3
provides the breakdown by publication type, showing that about half the papers
represent primary studies and reviews and half represent essays and editorials.
Table 1 describes the Canadian papers by type of APN, publication type and publi-
Figure 1.
Identification of papers for the scoping literature review
72 duplicates or
triplicates removed
CINAHL
612 articles
MEDLINE
1,523 articles
Web of Science
571 articles
40 articles included
for full text review
for data extraction
499 articles
2,397 articles
for full-text review
for data extraction
for data extraction
for data extraction
2,208 articles
EMBASE
262 articles
1,245 articles
eliminated based on
selection criteria
569 articles eliminated
after full-text review
48 documents submitted
by advisory board
research team,
and interviewees
10 articles retrieved
from hand searching
of key journals
189 duplicates or
triplicates removed
16 articles eliminated
after full-text review
459 articles
excluded based on
selection criteria
68 documents
included from search
of relevant websites
29 articles retrieved
from the reference list
of relevant articles
cation year. The majority of papers (70%) have been written since 2000, with 17%
focused on ACNPs, 47% on PHCNPs, 8% on NPs (type unspecified), 3% on CNS/
NPs, 10% on CNSs and 15% on APNs (type unspecified).
To analyze the extracted data, we used a combination of descriptive tables, narra-
tive syntheses (Mays et al. 2005) and team discussions. Each member of each
triad independently summarized the data she had extracted. Each triad then met
to discuss the tabulated data and their summaries. Three researchers (AD, IB
and KK) attended all triad meetings to enable cross-triad continuity. At the triad
Figure 2.
Papers in synthesis by geographic area (N = 468)
Australasia
0
12
322
Canada Europe
Geographic Area
Papers in Synthesis
US Various
International
50
100
150
200
250
300
350
34
97
3
Figure
3
.
Papers in synthesis by publication type (N = 468)
Editorial
4.1%
Primary Study
29.1%
Review
17.9%
Letter to
the Editor
0.2%
Essay
48.7%
meetings, the summaries prepared by team members were discussed to compare
and contrast themes and to formulate conclusions. The entire team then met to
discuss the results of the triad meetings and aggregate data across triads.
Key Informant Interviews and Focus Groups
In consultation with our advisory board, we used purposeful sampling to identify
key informants with a wide range of perspectives on advanced practice nursing
issues in Canada and internationally. The advisory board also assisted in develop-
ing a semi-structured interview guide, which was piloted on four participants.
Feedback from the pilot indicated that the questions were clear and comprehen-
sive and that the length of the interview was appropriate. All key informants were
asked the same set of questions, focusing on all types of APNs. The questions
included, for example, reasons for introducing the role(s) in their organizations,
region or province/territory; how the role(s) were implemented; key factors
facilitating and hampering their full integration at the individual, organizational
and system levels; the nature of their collaborative relationships; their impact;
success stories and recommendations for fully integrating the role(s). Individual
interviews were conducted by telephone or in person in English or French. We
also conducted four focus groups. All individual and focus group interviews were
audio recorded, transcribed and checked for accuracy.
Table 1.
Canadian papers by type of APN and publication year
Type of
APN
1970 to 1999 2000 to 2009 Overall (1970 to 2009)
Primary
study or
review
Editorial
or essay Total %
Primary
study or
review
Editorial
or essay Total %
Primary
study or
review
Editorial
or essay Total %
ACNP 7 3 10 9.5 15 34 49 20.1 22 37 59 16.9
PHCNP 27 34 61 58.1 61 43 104 42.6 88 77 165 47.3
General
NP
2 3 5 4.8 11 12 23 9.4 13 15 28 8.0
CNS/NP 1 3 4 3.8 2 4 6 2.5 3 7 10 2.9
CNS 2 7 9 8.6 13 12 25 10.2 15 19 34 9.7
General
APN
4 12 16 15.2 13 24 37 15.2 17 36 53 15.2
Total 43 62 105 115 129 244 158 191 349
a

ACNP = acute care nurse practitioner; APN = advanced practice nurse; CNS = clinical nurse specialist; NP = nurse practitioner;
PHCNP = primary healthcare nurse practitioner.
a
Total exceeds the number of Canadian papers in Figure 2 because some papers fit into more than one publication type category.
Table 2.
Key informant interviews (n = 62)
Type Number Location
Clinical nurse specialists 9 5 Canada (3 provinces)
4 United States
Primary healthcare nurse practitioners 8 5 Canada (3 provinces and 2 territories)
2 United States
1 United Kingdom
Acute care nurse practitioners 5 4 Canada (4 provinces)
1 United States
Health administrators 11 11 Canada (5 provinces)
Provincial government policy makers 6 6 Canada (5 provinces)
Nursing regulators 7 6 Canada (5 provinces and 2 territories)
1 Australia
Educators 5 3 Canada (3 provinces)
2 United States
Physicians 7 7 Canada (5 provinces)
Healthcare team members 4 4 Canada (3 provinces)
Data collection occurred between August 2008 and February 2009. We inter-
viewed 62 key stakeholders (Table 2) including CNSs (n = 9; five from three
provinces in Canada and four from the United States [US]); PHCNPs (n = 8; five
from three provinces and two territories in Canada, two from the US, and one
PHCNPresearcher from the United Kingdom [UK]); ACNPs (n = 5; four from
four provinces in Canada and one from the US); health administrators (n = 11
from five provinces); provincial government policy makers (n = 6 from five
provinces; five in chief-nursing-officer or nursing-policy-analyst positions and
one without a nursing background); nursing regulators (n = 7; six from Canada
representing seven provinces/territories [one regulator represented two territories]
and one from Australia); educators (n = 5; three from Canada representing three
provinces and two from the US); physicians (n = 7; three family physicians and
four specialists from five provinces); and four healthcare team members from
three provinces, including two RNs, one pharmacist and one respiratory therapist.
Four of the interviews were conducted in French and the remainder in English.
The 62 interview participants came from Canada (51), the US (9), the UK (1) and
Australia (1). Of the 51 from Canada, 14 were from the Western provinces, 18
were from Ontario, 8 from Quebec, 8 from the Atlantic provinces and 3 from the
three territories.
Three of the focus groups were a convenience sample of attendees at the
International Council of Nurses (ICN) International Nurse Practitioner/Advanced
Practice Nursing Network (INP/APNN) conference in Toronto in September
2008. An invitation to attend the focus group was included in the conference
package. A total of 15 individuals participated, representing all types of APNs, as
well as educators, administrators and policy makers. The majority of participants
were from Canada; others were from the US and Australia. Each focus group had
three to six participants and was conducted by two members of our research team,
one as interviewer and the other as recorder and observer. The fourth focus group
was a purposively selected sample of ACNPs (previously known as CNS/NPs)
from Ontario (four participants) who worked in the same setting.
In the interest of having as diverse and representative a sample as possible, we
chose to continue interviewing even after data saturation was achieved. In total,
through focus groups and interviews, we collected data from 81 individuals: four
focus groups with 19 attendees and 62 interviewees.
An initial coding structure of emergent themes from the interviews was developed
by the interviewer and one team member (IB). This draft coding structure was
then integrated by three team members (DBL, IB and AD) into a broader, theo-
retically informed framework based on two papers describing factors influencing
advanced practice nursing role integration (Bryant-Lukosius and DiCenso 2004;
Bryant-Lukosius et al. 2004). A spreadsheet was created to summarize codes,
themes and data from each transcript. Three team members (DBL, IB and AD)
and the four individuals who would be coding used the framework to independ-
ently code one transcript and discussed their coding. Two team members (JA
and KK) and two research assistants then used the framework to code all the
transcripts, following which they prepared summaries according to type of stake-
holder. Themes were compared across stakeholder type. Canadian and interna-
tional interviews were summarized separately. A French-speaking team member
(KK) coded French interviews.
In summarizing the results, we integrated findings from the scoping review and
interviews examining similarities and differences in themes and common patterns
and trends (Erzberger and Kelle 2003). For barriers and facilitators associated with
advanced practice nursing role integration, we concentrated on Canadian papers
written since 1990, because barriers or facilitators identified pre-1990 could be
outdated. This was especially likely given the implementation of regionalization
throughout Canada beginning about 1990.
Multidisciplinary Roundtable
Once we completed the synthesis and worked with our advisory board to derive
the implications of our findings, CHSRF convened a multidisciplinary roundtable
that included representatives from key nursing, medical, government, regulatory
and professional associations to develop pragmatic recommendations for policy,
practice and research (DiCenso et al. 2010b).
Discussion
Roundtable Recommendations
Roundtable participants made 11 key recommendations (DiCenso et al.
2010b). They are grouped below according to which of the key players in
our healthcare system would likely assume a leadership role for action or
implementation.
For the Nursing Community (and Partners)
1. The CNA should lead, in collaboration with other health professional
stakeholder groups (particularly the Canadian Medical Association and
the College of Family Physicians of Canada), the creation of vision state-
ments that clearly articulate the value-added role of CNSs and NPs across
settings, with close attention paid to roles in the delivery of primary
healthcare. These vision statements should include specific, yet flexible,
role descriptions pertinent to specific healthcare contexts, which would
help to address implementation barriers deriving from lack of role clarity.
For Senior Decision Makers (Policy and Practice)
2. A pan-Canadian multidisciplinary task force involving key stakeholder
groups should be established to facilitate the implementation of advanced
practice nursing roles.
3. Health human resources planning by federal, provincial and territorial
ministries of health should consider the contribution and implementation
of advanced practice nursing roles based on a strategic and co-ordinated
effort to address population healthcare needs.
4. A communication strategy should be developed (via collaboration
with government, employers, educators, regulatory colleges and profes-
sional associations) to educate nurses, other healthcare professionals, the
Canadian public and healthcare employers about the roles, responsibilities
and positive contributions of advanced practice nursing.
5. Advanced practice nursing positions and funding support should be
protected following implementation and demonstration initiatives to
ensure some stability and sustainability for these roles (and the potential
for longer-term evaluation) once they have been incorporated into the
healthcare delivery organization/structure.
6. In order to facilitate provider mobility in response to population health-
care needs and improve recruitment and retention to advanced practice
nursing roles, a pan-Canadian approach should be taken, in collabora-
tion with regulators, to standardize advanced practice nursing regulatory
standards, requirements and processes.
For Educators
7. In order to facilitate provider mobility in response to population health-
care needs and improve recruitment and retention to advanced practice
nursing roles, a pan-Canadian approach should be taken, in collaboration
with educators, to standardize advanced practice nursing educational
standards, requirements and processes.
8. The curriculum across all undergraduate and postgraduate health profes-
sional training programs should include components that address inter-
professionalism, in order to familiarize all health professionals with the
roles, responsibilities and scopes of practice of their collaborators.
For the Research and Research Funding Community
9. Further research should be conducted to quantify the impact of advanced
practice nursing roles on healthcare costs. The contexts of education,
effectiveness and length of career should be addressed within this research.
10. The focus of advanced practice nursing role effectiveness research should
shift away from replacement models and illustrate the value added of
these roles as compared to other nursing roles.
11. The CNS role in the Canadian context requires further study and should
be the focus of future academic work.
Strengths and Limitations
We used a variety of strategies to ensure comprehensive identification of
published papers and grey literature. As a result, we reviewed and retained in
the synthesis close to 500 papers representing English- and French-language
published and unpublished literature written about APNs in Canada as well
as international reviews published in the past five years. We used an elec-
tronic program to systematically extract the information from the papers,
with training and pilot testing of data extractors. While we identified many
relevant keywords to guide the searches, we may have missed papers that
used different keywords.
We conducted 62 interviews (four in French) and four focus groups with a
breadth of key informants, including all types of APNs, health administrators,
nursing regulators, educators, policy makers, physicians and members of
the healthcare team, most from Canada but also from the US, the UK and
Australia. While these are more interviews than we had proposed to conduct,
the number is still relatively small when considering the vastness of Canada
and the different constituencies represented. However, many of the themes
arose repeatedly across informant groups and were consistent with the litera-
ture. We interviewed at least one key informant from each province and terri-
tory (with one interviewee speaking about both Nunavut and the Northwest
Territories). The inclusion of French-language literature and French-speaking
key informants (interviewed in French) minimized the English-language bias
and enabled a fuller exploration of the issues throughout all of Canada.
While we interviewed seven physicians, we conducted only four interviews of
other members of the healthcare team: two RNs, a pharmacist and a respiratory
therapist. The APN relationship with these and other healthcare team members
(e.g., social workers) should be studied further. When our advisory board
reviewed the findings, they indicated that some of the data provided by key
informants may have been incorrect or incomplete, based perhaps on a limited
awareness of the issue; for example, some informants indicated that CNSs did
not provide direct patient care. This misperception reinforces the themes that
emerged from our synthesis regarding lack of role clarity and title confusion.
The collection of data from patient informants was beyond the mandate and
scope of this review. As new models of care emerge in the future, it will be
important to involve patients and families to identify their unmet needs.
Our interview data provide a snapshot of key issues identified from diverse
informant types across a variety of jurisdictions about different advanced
practice nursing roles. Most reviews of advanced practice nursing conducted
in Canada to date have focused on one APN type exclusively (e.g., PHCNPs).
While the breadth of this decision support synthesis has allowed us to exam-
ine issues across APN types, it may have compromised depth of explora-
tion of key issues for specific roles. For example, we were not able to sample
APNs from all sectors in which they work.
The advisory board assisted with identifying relevant jurisdictional and
organizational grey literature, reviewing the interview guide and suggesting
key informants to interview. To ensure comprehensiveness and objectivity
in the interpretation of our findings, the board also reviewed our report,
provided constructive feedback and assisted in identifying implications
based on our findings.
Dissemination Plans
The full report of the decision support synthesis is available in English and
French on the CHSRF website (DiCenso et al. 2010b). In addition to this
special issue of the Canadian Journal of Nursing Leadership, manuscripts that
target relevant topics for international and healthcare professional audiences
will be submitted to journals such as the Journal of Advanced Nursing and the
Canadian Medical Association Journal. We have presented our findings at key
national conferences and will continue to seek out these opportunities. We
have shared the findings with the provincial/territorial nurse advisors across
Canada. The Organisation for Economic Co-operation and Development
(OECD) surveyed 12 countries about APNs in 2009, and the Canada-specific
responses to the survey were largely informed by the decision support synthe-
sis findings (Delamaire and Lafortune 2010).
Tailored briefing notes that emphasize action plans will be prepared for
provincial/territorial Ministers and Deputy Ministers of Health, the Advisory
Committee on Health Delivery and Human Resources (ACHDHR), employ-
ers and program managers. We will collaborate with key organizations
such as the CNA, the Canadian Association of Advanced Practice Nurses
(CAAPN), the Canadian Association of Schools of Nursing (CASN), the
Academy of Canadian Executive Nurses (ACEN), the Canadian Healthcare
Association (CHA), the Canadian Medical Association (CMA) and the
College of Family Physicians of Canada (CFPC) to identify strategies for
targeted information exchange with the nursing and medical communities
and to identify medical and nursing champions to disseminate synthesis
findings and recommendations to internal groups and committees of their
professional associations and educational/regulatory bodies.
Conclusion
APNs have been part of the Canadian healthcare system for almost 40 years.
Their presence has expanded and contracted based on factors such as physi-
cian shortages and surpluses and hospital budgets. Three existing significant
reports have examined advanced nursing practice (CNA 2006) and more
specifically NPs (Canadian Nurse Practitioner Initiative 2006) and extended
nursing roles such as NPs in primary care from a Canadian perspective
(Advisory Committee on Health Human Resources & The Centre for
Nursing Studies in collaboration with The Institute for the Advancement
of Public Policy, Inc. 2001). Our synthesis differs from these earlier works
by providing an examination of CNS, ACNP and PHCNP roles through a
systematic scoping review of Canadian and international literature and by
conducting interviews and focus groups with national and international key
informants from a variety of stakeholder groups.
The findings of our synthesis demonstrate (1) the yet unfulfilled or unrealized
contributions APNs could make to address important gaps in maximizing the
health of Canadians through equitable access to high-quality healthcare serv-
ices, (2) the important interplay and influence of dynamic and often compet-
ing values, beliefs and interests of provincial and national governments,
healthcare administrators and health professions on the policies and politics
that shape the education, regulation and ad hoc deployment of advanced
practice nursing roles, and (3) the continued vulnerability of advanced prac-
tice nursing roles to changes in health policies and economic conditions.
The papers in this special issue both consolidate and augment our current
knowledge base about advanced practice nursing. These papers provide read-
ers with a comprehensive understanding of topics such as Canadas historical
journey in integrating APNs into our healthcare system; the inconsistencies in
educational requirements for PHCNPs across the country and limited access
to CNS-specific graduate education; the central issues and challenges to the
full integration of PHCNPs, ACNPs and CNSs in Canada; the important role
leaders play in supporting advanced practice nursing; and innovative PHCNP-
related approaches to increasing patient access to healthcare.
Acknowledgements
The synthesis from which this work was derived was made possible through joint
funding by the Canadian Health Services Research Foundation and the Office
of Nursing Policy of Health Canada. We thank the librarians who conducted
searches of the electronic databases, Tom Flemming at McMaster University and
Angella Lambrou at McGill University. Chris Cotoi and Rick Parrish in the Health
Information Research Unit (HIRU) at McMaster University created the electronic
literature extraction tool for the project. We thank all those who took time from
their busy schedules to participate in key informant interviews and focus groups.
Special thanks go to our advisory board, roundtable participants and Dr. Brian
Hutchison for their thoughtful feedback and suggestions.
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35
A Historical Overview of the
Development of Advanced Practice
Nursing Roles in Canada
Affiliate Faculty, CHSRF/CIHR Chair Program in Advanced Practice Nursing (APN)
Hamilton, ON
Halifax, NS
St-Jrme, QC
Oakville, ON
Hamilton, ON
Toronto, ON
Hamilton, ON
Abstract
Advanced practice nursing has evolved over the years to become recognized today
as an important and growing trend among healthcare systems worldwide. To under-
stand the development and current status of advanced practice nursing within a
Canadian context, it is important to explore its historical roots and influences. The
purpose of this paper is to provide a historical overview of the major influences on
the development of advanced practice nursing roles that exist in Canada today, those
roles being the nurse practitioner and the clinical nurse specialist. Using a scoping
review and qualitative interviews, data were summarized according to three distinct
time periods related to the development of advanced practice nursing. They are the
early beginnings; the first formal wave, between the mid 1960s and mid 1980s; and
the second wave, beginning in the late 1980s and continuing to the present. This
paper highlights how advanced practice nursing roles have evolved over the years to
meet emerging needs within the Canadian healthcare system. A number of influen-
tial factors have both facilitated and hindered the development of the roles, despite
strong evidence to support their effectiveness. Given the progress over the past few
decades, the future of advanced practice nursing within the Canadian healthcare
system is promising.
Introduction
Advanced practice nursing has evolved over the years to become recognized today
as an important and growing trend among healthcare systems worldwide (Sheer
and Wong 2008). It is defined as,
an advanced level of clinical nursing practice that maximizes the use
of graduate educational preparation, in-depth nursing knowledge and
expertise in meeting the health needs of individuals, families, groups,
communities and populations. It involves analyzing and synthesizing
knowledge; understanding, interpreting and applying nursing theory
and research; and developing and advancing nursing knowledge and the
profession as a whole (Canadian Nurses Association 2008: 10).
In Canada, the roots of advanced practice nursing can be traced to the efforts of
outpost nurses who worked in isolated areas such as the Northwest Territories,
CHSRF/CIHR Chair in APN
Hamilton, ON
37 A Historical Overview of the Development of Advanced Practice Nursing Roles in Canada
Labrador and Newfoundland during the early 1890s (Graydon and Hendry
1977; Higgins 2008). These early beginnings of advanced practice nursing have
been accepted but largely unrecognized within the Canadian healthcare system
(McTavish 1979). Since the 1960s, advanced practice nursing roles have become
more formalized within Canada.
To understand the development and current status of advanced practice nursing
within a Canadian context, it is important to explore its historical roots and influ-
ences. The purpose of this paper is to provide a historical overview of the major
influences on the development of advanced practice nursing roles that exist in
Canada today, those roles being the nurse practitioner (NP) and the clinical nurse
specialist (CNS).
Methods
This paper draws on the results of a scoping review of the literature and key
informant interviews conducted for a decision support synthesis commissioned
by the Canadian Health Services Research Foundation and the Office of Nursing
Policy in Health Canada. The overall objective of this synthesis was to develop a
better understanding of advanced practice nursing roles, their current use, and the
individual, organizational and health system factors that influence their effective
development and integration in the Canadian healthcare system (DiCenso et al.
2010a). The detailed methods undertaken for this synthesis are described in an
earlier paper in this issue (DiCenso et al. 2010b). Briefly, it consisted of a scoping
review of 468 papers that represent Canadian papers ever written about advanced
practice nursing and international reviews published between 2003 and 2008.
It also included 62 interviews and four focus groups with national and interna-
tional key informants, including CNSs, NPs, physicians, allied health providers,
educators, healthcare administrators, nursing regulators and government policy
makers. For this paper, the data have been summarized according to three distinct
time periods of advanced practice nursing development: the early beginnings; the
first formal wave, between the mid-1960s and mid-1980s; and the second wave,
beginning in the late 1980s and continuing to the present. Major historical drivers
for advanced practice nursing development during each of the two waves will be
described for the CNS and NP roles.
Early Beginnings of Advanced Practice Nursing
Informally, nurses have been practising in expanded roles in rural and remote
areas of Canada for some time, where nurses have for years been safely accept-
ing many responsibilities traditionally taken by family and general practition-
ers (Hodgkin 1977: 829). The chronic shortage of physicians in remote areas of
Canada, in particular, created a demand for nurses to work in these underserviced
areas. According to a national report (Kulig et al. 2003), the first outpost nurses
came from England in 1893 as part of the Grenfell Mission (Graydon and Hendry
1977; Higgins 2008). The mission, led by British medical missionary Wilfred
Grenfell, provided some of the earliest permanent medical services in Labrador
and northern Newfoundland (Higgins 2008). Before this mission, almost no
healthcare resources or formally trained nurses existed in the area. By 1920, nurse
midwives were recruited to rural areas of Newfoundland to provide healthcare
under challenging conditions (e.g., lack of professional support, lack of equip-
ment and resources, poor transportation and limited communication). Nurses
also practised in remote areas of other provinces. For example, an interview
participant from Saskatchewan describes the following:
Weve always had nurses working in expanded roles here in the prov-
ince from the early days, particularly in northern Saskatchewan. And it
started expanding particularly in the rural and northern areas for the
most part because of difficulty in finding continuous physician coverage
for those areas.
An NP who works in the Yukon elaborates further:
Historically, nurses have worked in an expanded capacity in remote
regions of northern Canada out of necessity, so when health services
were being regionalized in the north in the 1960s and they started look-
ing for nurses to work up here, they initially looked at midwives from
Britain because of the high birth rate and the aboriginal community, and
eventually, it just evolved that nurses had to take on many roles that were
traditionally within the medical realm, and doing things like suturing and
reading X-rays and those types of things, and so we have evolved. We are
almost, you could say, the first generation of the NP.
Drivers for Development of Advanced Practice Nursing Roles: Mid-1960s
to Mid-1980s
The major impetus for the formal development of advanced practice nursing,
particularly for the CNS role, was the fallout of World War II, in which the deple-
tion of experienced nurses on the home front during the war necessitated the
preparation of other nurses to fill this gap (Montemuro 1987: 106). More funds
were allocated to train and educate veteran nurses to meet societal needs (e.g., the
tuberculosis pandemic and the emergence of psychiatric nursing as a specialty),
leading to more specialty training and the development of advanced skills for both
junior and senior nurses. However, some nurses felt that their profession was not
ready to accept a more advanced and independent role within the healthcare system
(McTavish 1979). Others argued that nurses should seize the opportunity to develop
their profession because they believed that nurses were appropriately positioned
to meet societys emerging healthcare needs. Another controversial issue was the
potential medicalization of nursing and loss of a nursing philosophy of practice as
nurses in expanded and advanced roles took on functions traditionally performed
by physicians (Brown 1974; King 1974; MacDonald et al. 2005). During this time,
two types of advanced practice nursing roles emerged: the NP and the CNS.
Nurse Practitioner
In Canada during the mid 1960s and early 1970s, the major driving forces for
implementing the NP role (also known as an expanded role or the family prac-
tice nurse) (Allen 1999; Chambers and West 1978a; Glass et al. 1974; King 1974)
were (1) the introduction of universal publicly funded medical insurance, (2) the
perceived physician shortage, (3) the increased emphasis on primary healthcare,
and (4) the trend toward increased medical specialization (Angus and Bourgeault
1999; de Witt and Ploeg 2005; Torrance 1998; van der Horst 1992). In response, the
Boudreau report (1972) was released, receiving widespread acceptance across the
country. It recommended that NPs be trained to meet primary healthcare needs
in Canada, proposing that NPs could be the first contact for people entering the
healthcare system (Nurse Practitioner 1978). Boudreau (1972: 7) contended that
the NP should be an extension of the present nursing role, with the nurses unique
skills in the provision of health care being developed and utilized more effec-
tively, and the nurses role in assisting the physician expanded through increased
delegation of certain tasks by physicians to suitably prepared nurses. Following
this report, the Canadian Nurses Association (CNA) and the Canadian Medical
Association (CMA) issued a Joint Statement (CNA and CMA 1973) that addressed
priorities, roles and responsibilities, education and work situations for nurses
working in expanded roles (Witter du Gas 1974). The statement recognized the
interdependent nature of nursing and physician roles and envisioned increased
nursing responsibilities for health maintenance (Canadian Medical 1973).
Provincial nursing groups across Canada led a number of initiatives aimed at
legitimizing expanded nursing roles (Baumgart and Grantham 1973; Nurse
Practitioner 1978), such as the development of (1) the Nurse Practitioners
Association of Ontario (1973), (2) the British Columbia Committee on the
Expanded Role of the Nurse in Provision of Health Care (1973), (3) the
Saskatchewan Nurse Practitioner Demonstration Project (Cardenas 1975),
(4) the Manitoba Nurse Practitioner Interest Group (1975), (5) the Report on
Nurses in Nova Scotia Performing in an Expanded Role (1975), and (6) a report
entitled Employment Opportunities for Nurse Practitioners in Alberta (1977).
Soon after the Boudreau report and the CNA/CMAs Joint Statement were released,
a number of educational programs were developed across Canada to prepare
nurses for expanded roles. Two types of programs emerged: one that prepared
nurses to provide health services in outpost settings and in remote areas of north-
ern Canada, and another that focused on developing nurses with primary care
skills to work in family practice settings or in community nursing roles (Nurse
Practitioner 1978). Dalhousie University in Nova Scotia led the way by establish-
ing the first program for midwifery and outpost nursing in 1967; six other univer-
sities (Alberta, Manitoba, Western Ontario, Toronto, McGill and Sherbrooke)
followed suit in 1972. The curriculum for these programs was influenced by the
Kergin Report (Kergin 1970), with the goal of preparing clinically trained nurses
(CTNs) to practise in isolated settings (Hazlett 1975). McMaster University and the
University of Montreal started programs in 1971 that focused on preparing family
practice nurses to work in urban settings. Other similar university programs
began later at the University of British Columbia and Memorial University.
Several program descriptions were published (Chambers et al. 1974; Herbert
and Little 1983; Kergin and Spitzer 1975; Kergin et al. 1973; Spitzer and Kergin
1973, 1975); their curricula emphasized preparing nurses to work collaboratively
with physicians but in more independent and expanded roles. For example, at
McMaster, physicians had to agree to take on the nurse and to attend certain
clinical and educational sessions with the nurse. Spaulding and Neufeld (1973:
98) described the McMaster program positively: The nurses learn enough history
taking and physical examination to carry out the initial assessment of patients,
most prenatal and postnatal care, well-baby care, and the management of certain
diseases such as hypertension and diabetes. However, programs varied across
institutions, with Dalhousie University offering a two-year diploma and McMaster
offering an eight-month program beyond a baccalaureate degree or a diploma.
A key issue for facilitating the development of advanced practice nursing roles
was the debate about educational requirements for entry-to-practice during
the early 1970s, with recommendations for baccalaureate education for NPs
(Buzzell 1976; Riley 1974) and masters level for CNSs (Boone and Kikuchi 1977).
Moreover, arguments for increased standardization of NP education were made
and continue to be debated today (Canadian Nurse Practitioner Initiative 2006;
Hubert et al. 2000; Schreiber et al. 2005). Confusion regarding the required educa-
tional preparation for advanced practice nursing roles has contributed to the
slow acknowledgement, growth and integration of these roles into the Canadian
healthcare system (Schreiber et al. 2005).
Several pilot or demonstration projects were subsequently initiated across the
country, as suggested in the Boudreau report. Generally, evaluation of these projects
was positive; 93% of NPs gained employment, more time was spent with patients,
NPs reported doing less clerical work, and job satisfaction stayed the same for MDs
and NPs (Scherer et al. 1977; Spitzer et al. 1975). Using a descriptive survey, Chenoy
et al. (1973) found that patients had favourable views about nurses being involved
in health promotion activities, but they preferred physicians in worry-inducing
situations. In isolated settings such as northern Newfoundland or Ontario, outpost
nurses were responsible for providing primary care to the entire community and
for seeing patients in clinics for preventative health, prescription refills or common
problems such as upper and lower respiratory infections (Black et al. 1976; Dunn
and Higgins 1986; Graydon and Hendry 1977). A pilot evaluation of four NPs
working in rural Saskatchewan showed that role implementation varied according
to community needs (Cardenas 1975). Research also supported the NP role in pedi-
atric settings (McFarlane and Norman 1972), outpatient clinics (King et al. 1974;
Ramsay et al. 1982) and emergency settings (Vayda et al. 1973).
Rigorous evaluation studies of NP outcomes were also conducted during this
time. In Ontario, two landmark randomized controlled trials, often referred to
as the Burlington Trial (Sackett et al. 1974; Spitzer et al. 1974) and the Southern
Ontario Study (Spitzer et al. 1973a, 1975), demonstrated the effectiveness of the
NP role. The studies showed that NPs could safely manage 67% of the problems
reported in a family practice setting and that patients were satisfied with NP care
(Batchelor et al. 1975; Sackett et al. 1974; Spitzer et al. 1976). Studies conducted
in Newfoundland showed positive results, adding further support for the safety
and effectiveness of NP roles (Chambers and West 1978a). NPs were also found
to improve resource utilization and access to care (Chambers 1979; Denton et al.
1983; Kushner 1976; Lees 1973; Lomas and Stoddart 1985; Spitzer et al. 1973a)
and to increase primary care services in the community (Chambers et al. 1977).
Despite the strong research evidence supporting the effectiveness of NPs, integra-
tion and sustainability of this role failed during the 1970s. A number of factors
led to the failure, but the primary reason was lack of funding for NP services
(Chambers and West 1978b; Mitchell et al. 1993). Since provincial ministries of
health did not provide funding for NPs, physicians who partnered with NPs had
to pay their salaries out of their income. This arrangement soon created a financial
loss and disincentive for physicians to work with NPs because they were unable to
bill for unsupervised NP services (Jones 1984; Spitzer et al. 1973b). Other factors
included a perceived oversupply of physicians, particularly in urban areas; lack of
NP role legislation for an extended scope of practice; insufficient public awareness
of the role; and inadequate support from policy makers and other health provid-
ers (Mitchell et al.1993). In particular, lack of support from the medical commu-
nity created substantial tension around NP role implementation (Haines 1993).
The direct relationship between the perceived demand for NPs and the undersup-
ply of physicians as the traditional and primary driver for NP services was trou-
blesome for the sustainability of the NP role. While comparing the different ways
that the expanded role in nursing was implemented across the country during the
1970s, Allen (1977, 1999) found that it was perceived in one of two ways: either as
a replacement function or a complementary one. In the former, NPs were vulner-
able to the supply of physicians and considered an assistant to the physician,
whereas in the latter, the emphasis was on the unique and added value of NPs and
their co-existence with others as a distinct healthcare professional.
Moreover, a double standard existed, whereby NPs were supported to practise in
areas where physicians did not want to (i.e., rural and remote communities), but,
otherwise, there was little perceived need for the role (CNA 2006; de Witt and
Ploeg 2005). Similar opinions of the NP role existed in the United States and may
have influenced the way it was perceived in Canada. For example, Roemer (1976:
41), a family physician, compared NPs to medical corpsmen discharged from the
military services, stating that NPs were acceptable for servicing the poor and that
in America or other affluent nations, to abandon primary care to others [such as
NPs] is to acknowledge failure in medicine and inequity in society.
Other physicians have been more supportive of NP role integration within the
healthcare system. In 1978, the president of the College of Family Physicians of
Canada, Dr. Hollister King, noted that the family practice nurse was never intended
to provide cheaper medical care for the citizens of our country, but rather compre-
hensive care that the Canadian public would soon learn to appreciate (King 1978:
21). Many of the 250 NPs who graduated from Canadian university programs
between 1970 and 1983 continued to practise through the 1980s and 1990s, prima-
rily in community health centres and northern remote health centres (Haines 1993).
Clinical Nurse Specialist
The impetus for the introduction of CNS roles arose after World War II, when the
shortage of skilled nurses and progressive developments in healthcare science and
technology led to the need for more advanced and specialized nursing roles and
nurses with the knowledge and skills to support nursing practice at the bedside.
An educator interview participant from Quebec comments:
The CNS was introduced mainly in acute care I think the main reason
why we introduced the CNS role was because the level of care was getting
more and more complex we needed these CNSs in larger hospitals to
promote a greater level of care and to promote continuing training [and]
coaching and to create a dynamic in the nursing care field to improve the
level of care. I think this was the main driver to include the CNS in the field.
The term specialist was one of the first used to describe what is today the clini-
cal nurse specialist. In 1943, Frances Reiter introduced the term nurse clinician
to describe a nurse with advanced knowledge and clinical skills who was capable
of providing a high level of patient care (Davies and Eng 1995; Hamric et al. 2009;
Montemuro 1987; Reiter 1966). Over time, the CNA has put forth many iterations
of Reiters definition for the CNS role (1978, 1986, 2009).
Although not specifically designed to educate or produce CNSs, the University
of Toronto introduced a masters degree program in nursing in 1970 that offered
a focus on clinical specialization. By 1986, most CNSs practising in the role were
prepared at a masters level (Montemuro 1987). Beaudoin et al. (1978) argued
that the CNS role was more in keeping with nursing values, as opposed to the NP
role, which was described as an extension of medicine because of the medical role
functions it incorporated. Stevens (1976: 30) contended that the CNS role has
contributed so much, so rapidly, in attempts to professionalize nursing and to
substantiate its existence as an independent profession.
The CNS role development and implementation was often challenged by issues
related to role ambiguity, lack of involvement or recognition in the organizational
structure, and lack of administrative support (Davies and Eng 1995; Hagan and
Ct 1974; Ingram and Crooks 1991; Montemuro 1987). A quote from a health-
care administrator participant supports these claims:
I think what happened starting back in the late 60s or 70s, nurses who
were prepared at the masters level employers knew they wanted them
and needed them, but they didnt quite know what to do with them, so
they put them into CNS roles and that has happened over the last 20 or
so years. So the role is very varied and not very well understood I think
that is part of the problem with the successful implementation you dont
have a clear role that you are implementing .... I think it is historical, it just
happened that way. Its not a bad thing; that is just the history of the role.
Drivers for Development of Advanced Practice Nursing Roles:
Late 1980s to Present
A number of initiatives related to advanced practice nursing were implemented
at the federal level, for example, (1) the CNAs (2006) Dialogue on Advanced
Nursing Practice (ANP), (2) the decade-long development and revisions to the
Advanced Nursing Practice framework (CNA 2000, 2002, 2008), (3) a 10-year
Chair Program (20012011) funded by the Canadian Health Services Research
Foundation (CHSRF) and the Canadian Institutes of Health Research (CIHR) to
increase Canadas capacity of nurse researchers to conduct policy and organiza-
tionally relevant research focused on advanced practice nursing, and (4) a deci-
sion support synthesis funded by the CHSRF, in partnership with the Office of
Nursing Policy of Health Canada, to inform the integration of CNSs and NPs in
the Canadian healthcare system (DiCenso et al. 2010a).
At the provincial level, numerous initiatives have supported advanced practice
nursing roles; for example, the Association of Registered Nurses of Newfoundland
(1997) developed a Plan of Action for the Utilization of Nurses in Advanced
Practices throughout Newfoundland and Labrador, the Registered Nurses
Association of Nova Scotia (1999) developed a Position Paper on Advanced Nursing
Practice, and CHSRF supported work that resulted in a report on Advanced Nursing
Practice: Opportunities and Challenges in British Columbia (Schreiber et al. 2003).
Nurse Practitioner
Due to rising healthcare costs during the early 1990s, a number of government-
initiated healthcare reforms occurred with the goals of using resources more effi-
ciently and placing more emphasis on health promotion and community-based
care (Angus and Bourgeault 1999; deWitt and Ploeg 2005; Stoddart and Barer
1992). Stoddart and Barer (1992), in their national report Toward Integrated
Medical Resource Policies for Canada, argued for a reduction in the number of
physicians in the healthcare system, recommending that other healthcare profes-
sionals should be substituted for physicians, in which their superior effectiveness,
appropriateness or efficiency has been demonstrated (Stoddart and Barer 1992:
1654). Also, the release of the Regulated Health Professions Act (1991) weakened
medicines jurisdictions by preventing any single profession from monopolizing
health care (deWitt and Ploeg 2005: 126). As a result, key tasks were organized
and allocated according to their appropriateness for individual professions (Angus
and Bourgeault 1999). In the meantime, concerns emerged about a future over-
supply of physicians in urban settings, while rural and remote areas continued to
be underserviced (deWitt and Ploeg; Haines 1993). All of these factors created a
renewed interest in advanced practice nursing roles in the early 1990s, particularly
for the NP role in Ontario. An interview participant adds,
They [NPs] were part of solutions for other problems, for example, if
there were times of shortages in primary care physicians and those sorts
of things. When we got to the 90s, we recognized through a number of
reports that there needed to be revitalization of primary care and that
advanced practice roles may well be an important part of increasing access
to primary care. Then the nurse practitioner program was reintroduced.
During the early 1990s, many nursing professional organizations began to advocate
for revitalizing the NP role across Canada (Haines 1993). However, in Ontario,
the new regulations proposed by the Ontario Ministry of Health and Long-Term
Care to increase the scope of practice of NPs created concern from the Ontario
Medical Association and the Ontario College of Family Physicians. They argued
that NPs would be more expensive and that the evidence used to support NP utili-
zation in Ontario was flawed (Evans et al. 1999). Despite these arguments, two
reports provided recommendations to the contrary one commissioned by the
CNA (Haines 1993) and another prepared at the request of the Ontario Ministry of
Healths Nursing Secretariat (Mitchell et al. 1993). The Ontario government funded
a consortium of 10 universities to mount a common post-baccalaureate primary
healthcare NP educational program, beginning in 1995 (Cragg et al. 2003).
The momentum to support NP roles continued into the twenty-first century
with the completion of two prominent studies: (a) The Nature of the Extended/
Expanded Nursing Role in Canada (Advisory Committee on Health Human
Resources et al. 2001), and (b) Report on the Integration of Primary Health Care
Nurse Practitioners into the Province of Ontario (DiCenso et al. 2003). Also,
two national reports (Kirby 2002; Romanow 2002) that have been influential in
advancing the NP role were released. The Romanow report emphasized strategies
to reduce wait times and suggested improvements to primary healthcare, includ-
ing using nurses in case manager roles and better utilization of NPs:
Across Canada, there has been an increasing emphasis on the role of
nurse practitioners who can take on roles that traditionally have been
performed only by physicians. This could even include providing nurse
practitioners with admitting privileges to hospitals so that they could refer
patients and begin initial treatment in hospitals (Romanow 2002: 106).
A new NP role emerged in the late 1980s, called the blended CNS/NP. This role
was first introduced in Ontario in tertiary-level neonatal intensive care units
(NICUs) to help offset the cutbacks in pediatric residents (Hunsberger et al. 1992;
Pringle 2007). The addition of CNS to the title was deliberate, to legitimize the
nonclinical advanced practice role dimensions, including education, research and
leadership (DiCenso 1998; Hunsberger et al. 1992). A healthcare administrator
interview participant describes:
The individuals who came into those roles [CNS/NP] very much valued
their background in nursing. They used their nursing knowledge, their
assessment, their intervention, their skills and capacity to work with
families, provide education to nurses their view of the world was very
much about the holistic needs of the patient and family and their desire to
provide mentorship and professional development for nurses. All of those
things came together for those individuals who were in that role, and
they really saw themselves as providing components of the clinical nurse
specialist role as well as the more medical components of the nurse prac-
titioner role, and they did not want to give that up. They didnt want to be
slotted into the view that they were medical replacements, because they
really perceived themselves to be much more. And they are much more.
NPs in these roles were soon introduced into other specialty areas within hospitals
because of a shortage of medical residents and lack of continuity of care for seri-
ously ill patients (Pringle 2007). A few years later, as our focus group participants
informed us, advanced practice nurses in these roles were renamed acute care
NPs (ACNPs). The term ACNP was first coined in the United States to describe
NPs working in critical care (Kleinpell 1997); it was later adopted in Canada in
the mid-1990s to describe NPs working with specialized populations in acute care
settings (Simpson 1997).
In contrast to the primary healthcare NP (PHCNP) programs, all ACNP educa-
tion programs were developed at the graduate level throughout Canada (Alcock
1996; Dunn and Nicklin 1995; Facult des sciences infirmires, Universit de
Montral 2008; Haddad 1992; Roschkov et al. 2007). An interview participant
offers her perspective about the ACNP programs:
I think nursing leaders in organizations saw that as an opportunity to
start to explore the nurse practitioner role for acute care. The University
of Toronto in the early 90s put together a program I guess it was around
1994 if Im not mistaken and that program has been evolving since that
time at U of T. It started out to be a program that was a post-masters
program that was offered to clinical nurse specialists.
The introduction of the ACNP role in neonatology in Ontario was based on
a comprehensive research program (DiCenso 1998) that began with a needs
assessment (Paes et al. 1989). This was followed by surveys to delineate the role
(Hunsberger et al. 1992), evaluations of the graduate-level education program
(Mitchell et al. 1991, 1995), a randomized controlled trial to evaluate the effective-
ness of the role (Mitchell-DiCenso et al. 1996a) and assessments of team satisfac-
tion with the role (Mitchell-DiCenso et al. 1996b). A healthcare administrator
interview participant adds,
I think theres absolutely no question that the nurse practitioner role, and
particularly in NICU, has been very positive. I mean its only enhanced
the quality of the care that the infants receive; its enhanced the continu-
ity of care that the infants receive; its enhanced the linkages and support,
education and emotional support with families; and its assisted in
developing probably better collaboration among the teams and all of the
disciplines that work [there].
Advanced practice nursing roles have evolved differently across provinces and terri-
tories for a number of reasons. In Quebec, the ACNP was the first NP role formally
introduced into the healthcare system, according to this healthcare administrator:
The first wave that the government allowed was in neonatal ICU, cardi-
ology/cardiovascular and nephrology, and the reason why those were
chosen versus lets say something like primary care was because politically
it was a specialist in the university teaching hospitals who wanted, who
really backed the support of advanced practice nurses and lobbied within
their associations and at a larger collective with the government to say,
we absolutely need these people ... on the other hand, the group of family
practice professionals here in Quebec opposed the NPs.
Prior to 1998, all acute and primary care NPs working in Canada utilized medi-
cal directives or care protocols, under the delegation of physicians, to perform the
competencies of their training that were beyond the scope of a registered nurse.
In 1998, the first legal recognition for NP scope of practice began with legislated
authority for primary care NPs in Ontario (CIHI and CNA 2006). Many jurisdic-
tions implemented regulations for both PHCNPs and specialty/ACNPs at the
same time (i.e., Alberta, British Columbia, Manitoba, Newfoundland, and Nova
Scotia). Each jurisdiction provided the authority whereby the ACNPs professional
scope of practice was defined (CIHI and CNA 2006). However, there were many
barriers to practice. For example, the Public Hospitals Act in Ontario prohib-
ited NPs from admitting or discharging a patient. Because of the Act, ACNPs in
Ontario require medical directives even with regulation of their role. Jurisdictions
where ACNPs have not been regulated require medical directives, negotiated at the
institutional level, for ACNPs to carry out extended controlled acts. In most prov-
inces and territories, successful completion of a national (or in some cases provin-
cial) examination is a requirement for NP licensing. Currently the CNA offers
examinations for family/all-ages (PHCNPs), adult NPs and pediatric NPs (for
more information see http://www.cna-nurses.ca/CNA/nursing/npexam/default_e.
aspx). Eligibility of candidates and permission to take these exams are determined
by provincial/territory regulatory bodies. In Quebec, NPs must have a specialty
certification in order to practise.
In 2005, the federal government provided funding for the Canadian Nurse
Practitioner Initiative (CNPI), sponsored by the CNA. The CNPI mandate was
to develop a framework for the integration and sustainability of the NP role in
Canadas healthcare system (CNPI 2006). The final report, Nurse Practitioners:
The Time is Now, along with its companion technical reports, includes discussion
papers on (1) standardization of NP education, (2) regulation, (3) recruitment
and retention, (4) professional practice and liability and (5) the core competency
framework for NPs (CNPI 2006).
During the second wave of implementing the NP role in Canada, new challenges,
particularly for nurses in rural and remote settings, emerged as NPs continued to
develop. For instance, the variation in education, regulation and credentialling
raised concerns about the competency of some NPs by both nursing and medi-
cal colleagues. This had negative consequences for establishing the credibility
and legitimacy of the roles (Advisory Committee on Health Human Resources
et al. 2001). Also, the requirement for NP licensure, and in some provinces
masters education, created difficulties for nurses who practised in rural and
remote regions throughout Canada. In 2008, only 5.9% of all registered nurses
(RNs) practising in rural and remote areas in Canada were NPs, with the highest
percentage in the territories (11.5%) and lowest in the Atlantic provinces (2.1%)
(Stewart et al. 2005). Stewart and colleagues found that these nurses reported a
need for more education, particularly for practice in remote areas. In addition,
although primary care delivery to First Nations and Inuit communities has been
improved by using NPs, an increased scope of practice has led to the need for
higher education for NPs (Health Canada, and First Nations and Inuit Health
Branch 2006). As a result, decreased numbers of RNs were able to practise as NPs
in First Nations because of strict criteria for registration with the provincial and
territory regulators (Health Canada, and First Nations and Inuit Health Branch
2006). A healthcare administrator interview participant elaborates on this issue:
In 2002 the government changed legislation around NPs. Prior to that in
Alberta, NPs were only working in our very remote northern areas of the
province. So in 2002 the legislation changed, and the regulation was such
that for people to practise as an NP they had to be registered on a roster
with CARNA [College and Association of Registered Nurses of Alberta].
So at that point, we were starting at ground zero because there werent any
[licensed] ones [NPs].
Similar activities were occurring in Saskatchewan at about the same time, as a
government stakeholder adds,
Now back in the early 90s, it was recognized that the nurses were requir-
ing more consistent education to work in these roles, particularly in the
north. So an Advanced Clinical Nurse course was organized through the
Saskatchewan Institute of Applied Science and Technology. This course
started in 1993 and consisted of about six courses to help nurses upgrade
their education in diagnosis and prescribing of medications and common
treatments like suturing.
Efforts have focused on overcoming some of the challenges that were previously
experienced during the first wave of implementing NPs. For example, in Alberta,
the Taber Project represents one initiative that was recognized as being a successful
model in implementing the role of the NP (Reay et al. 2006). The success was largely
due to the NP funding model, whereby costs were shared between the clinic and the
provincial government so that the improved billing potential surpassed the costs of
employing the NP (Reay et al. 2006). In most jurisdictions, the government pays for
NP salaries because direct billing of provincial insurance plans is not permitted.
All provinces and all territories currently have legislation in place for the NP role
(Government of Yukon 2009; Hass 2006). Alberta was the first province, in 1996,
to legislate NPs to practise, and the Yukon was the most recent to pass legislation
for NPs, in December 2009 (Government of Yukon, 2009; see Table 1). As of fall
2009, there were almost 2500 licensed NPs in Canada, over half of whom were in
Ontario (see Table 1). National leaders in advanced practice nursing propose that
the establishment of pan-Canadian legislation for NPs marks the beginning of a
third wave of development of the NP role, one characterized by the recognition
of NPs as essential components of the Canadian healthcare system (CNA 2006).
Table 1.
NPs in Canada year of legislation and workforce numbers
by province
Province Year legislation was passed
Nurse practitioner workforce
(as of fall 2009)
Newfoundland 1997 104
Prince Edward Island 2006 3
Nova Scotia 2002 96
New Brunswick 2002 57
Quebec 2003 41
Ontario 1997 1,463
Manitoba 2005 75
Saskatchewan 2003 120
Alberta 1996 294
British Columbia 2005 129
Yukon 2009 NA
Northwest Territories/Nunavut 2004 60
Total 2442
Source: provincial/territorial regulators
NA=There are no licensed NPs in Yukon yet, as legislation just passed in 2009.
Clinical Nurse Specialist
Unlike the NP, the CNS role continued to formally exist and be supported during
the 1980s and did not experience the same wave effect as the NP role did. However,
the CNS role experienced different forms of ebbs and flows, largely reflective of the
current needs and economic situation of the Canadian healthcare system.
In 1986, the CNA released its first position statement on the CNS role, describing
it as,
an expert practitioner who provides direct care to clients and serves as a
role model and consultant to other practising nurses. The nurse partici-
pates in research to improve the quality of nursing care and communicates
and uses research findings. The practice of the clinical nurse specialist is
based on in-depth knowledge of nursing and the behavioural and biologi-
cal sciences. A CNS is a registered nurse who holds a masters degree in
nursing and has expertise in a clinical nursing specialty (CNA 1986: 1).
Following this report, two provincial statements on the CNS role were released
one by the Registered Nurses Association of Ontario (1991) and another by
the Registered Nurses Association of British Columbia (1994) that identified
the major components of the CNS role as clinical practice, education, research,
consultation and leadership/change agent. These components of the CNS role
have remained constant throughout two subsequent iterations of CNA position
statements on the CNS role in 2003 and 2009 (CNA 2003, 2009).
However, in Quebec, the inclusion of a clinical component to the CNS role has
been a long-standing point of discussion among the licensing board, research-
ers and healthcare providers (Allard and Durand 2006; Beaudoin et al. 1978;
Charchar et al. 2005; Laperrire 2006; Ordre des infirmires et infirmiers du
Quebec (OIIQ) 2002, 2003; Roy et al. 2003). Historically, the lack of a clinical
component was due to a shortage of masters-trained nurses and the need to
strategically place them in administrative roles (Beaudoin et al. 1978). Yet inter-
national leaders in advanced practice nursing argue the clinical component is the
hallmark of the CNS role (Hamric and Spross 1989).
Table 1 Continued.
One of the most significant developments in advancing the CNS role across
Canada was the formation of a national interest group, initially called the
Canadian Clinical Nurse Specialist Interest Group (CCNSIG) in 1989. Leaders
within this group worked closely with CNSs from other provinces to help develop
their own provincial organizations as well as organize conferences to advance
their professional practice. In 1991, CCNSIG became an associate group of CNA.
By 1998, CCNSIG was renamed the Canadian Association of Advanced Practice
Nurses (CAAPN), to include other types of advanced practice nurses.
According to Hamric et al. (2009), the 1990s was a challenging decade for the
sustainability of the CNS role in the United States due to financial problems and
cutbacks within the healthcare system. During this time, CNSs tended to assume
different positions such as administrators or staff educators (Hamric et al. 2009).
However, toward the end of that decade, interest in the CNS role returned with the
intent of bringing clinical leadership back into healthcare environments; this leader-
ship was lacking due to reductions in nurse executive and nurse educator positions.
The movement toward evidence-based practice has created greater need for the
CNS role in practice settings to help staff nurses incorporate research into practice.
Unlike for NPs, no formal education program in Canada has been developed
specifically for CNSs. Although graduate education is a standard precursor to
becoming a CNS, graduate programs have not been specifically designed to meet
the needs of CNSs but, rather, tend to be more generalized in nature. As a current
co-chair of the CNS Council of Canada, Gauthier (2009) recommends standard-
izing CNS education across Canada at the specialization level, with a requirement
of 500 clinical hours for a masters degree. This has been accepted as a require-
ment for CNSs practising in the United States. However, Calkin (2006) argues that
the lack of clarity about the meaning of specialization in nursing and its relation-
ship to advanced practice nursing has created barriers to embedding advanced
practice nursing within the Canadian healthcare and educational systems. She
claims disciplinary education is the basis for graduate education for CNSs who
develop a knowledge base and skills in applying concepts to healthcare challenges
well beyond those developed in their basic education (2006: 48). According to
Alcock (1996), the most common areas of clinical specialization for the CNS were
psychiatry, maternal/child, gerontology, palliative care, womens health, commu-
nity health, oncology and pediatric chronic care.
In Quebec, the regulatory body, the Ordre des Professions, determines each
professional groups scope of practice and regulates the use of the title Specialist
(Bussires and Parent 2004). Professionals must complete specialized training in a
recognized university program to use the terms specialized or specialist.
Challenges to the development of the CNS role that were apparent during its
initial implementation in the 1970s continued to plague its implementation in
later years (Davies and Eng 1995; Fulton and Baldwin 2004; Ingram and Crooks
1991; Montemuro 1987). For example, Davies and Eng (1995) found that a
complex interplay of factors including role clarity, organizational structure and
administrative support influenced how well the CNS role was implemented.
Moreover, the diversity and range of functioning among CNSs were apparent
across healthcare agencies, with most of their time devoted to four compo-
nents: practice, consultation, education and research (Davies and Eng 1995).
Recommendations have been put forth to address some of these issues, such as
standardizing the CNS role, by developing clear role definitions and promoting
the use of similar job descriptions and position titles (CNA 2006). Basic structures
and resources are also required to support the development of CNS roles and
promote their sustainability within the Canadian healthcare system, such as stand-
ardized education, credentialling and regulation (Bryant-Lukosius et al. 2010).
Evaluations of the CNS role have been consistently positive, with improvements
demonstrated in patient health status and satisfaction, quality of life, quality of care,
health system costs and length of stay (Fulton and Baldwin 2004). However, very
little of the research has been conducted in Canada (Bryant-Lukosius et al. 2010).
Based on CIHI data (2010), there were about 2,227 CNSs in Canada in 2008
(Table 2); however, the true number of CNSs is unknown because current CNS
estimates are based on self-report and many of these individuals lack graduate
education or specialty-based experience. Based on these data, the largest numbers
of CNSs are found in British Columbia, Quebec and Ontario.
Table 2.
CNSs in Canada workforce numbers by province for 2009
Province Clinical nurse specialist workforce
Newfoundland 25
Prince Edward Island 5
Nova Scotia 48
New Brunswick 25
Quebec 555
Ontario 415
Manitoba 115
Saskatchewan 63
Alberta. 303
British Columbia 663
Yukon NA
Northwest Territories/Nunavut 10
Total ~2,227
Source: Canadian Institute for Health Information (CIHI 2010)
NA=Data not applicable or do not exist.
CNS positions are often vulnerable to being reduced or eliminated during times
of poor hospital economic situations or financial cutbacks (CNA 2009). With the
increased focus on NP roles and lack of recognition of the valued contribution of
CNSs, some employers have shifted funding from CNS to NP positions (CNA 2006).
Variability in CNS practice and the many role dimensions have led to role confusion
and have made evaluation of role outcomes challenging (CNA 2006; Sparacino and
Cartwright 2009). As a result, organizations and administrators struggle to appreci-
ate CNS contributions for achieving clinical and institutional outcomes.
Momentum seems to be building in recognizing the importance and value of the
CNS role internationally. For example, the American Nurses Credentialing Center
(ANCC) recommends employment of CNSs for hospitals to achieve magnet
status. To be deemed a magnet hospital, specific criteria need to be satisfied as
a reflection of the strength and quality of nursing services. These include using
evidence-based nursing to achieve excellent patient outcomes and maintaining a
high level of job satisfaction and low staff nurse turnover rate (Center for Nursing
Advocacy 2009). Walker et al. (2009) found that CNSs were perceived as important
in achieving and maintaining magnet status within American hospitals. Within
Canada, as concern over the quality of care builds in the 21st century, there is
reason to believe that the CNS role will regain prominence (CNA 2008: 6).
Conclusion
Advanced practice nursing has evolved to meet gaps and emerging needs
in the healthcare system. This historical analysis of the development of
advanced practice nursing roles in Canada highlights a number of influen-
tial factors that have both facilitated and hindered the development of the
roles, despite strong evidence to support their effectiveness. Understanding
the theoretical, empirical and experiential efforts and achievements of the
visionary leaders of the past will better position advanced practice nursing to
Table 2 Continued.
meet the healthcare needs of Canadians into the future. Given the progress
over the past few decades, the future of advanced practice nursing within the
Canadian healthcare system is promising.
Acknowledgements
The following staff members provided excellent support: Heather Baxter, Renee
Charbonneau-Smith, R. James McKinlay, Dianna Pasic, Julie Vohra, Rose Vonau,
and Brandi Wasyluk. Special thanks go to our Advisory Board, Roundtable partici-
pants and Dr. Brian Hutchison for their thoughtful feedback and suggestions.
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61
Education of Advanced Practice
Nurses in Canada
Associate Professor & Associate Director, Graduate Programs, School of Nursing
Dalhousie University, Halifax, NS
Director, Canadian Centre of Excellence in Oncology Advanced Practice Nursing (OAPN)
at the Juravinski Cancer Centre
Hamilton, ON
Oakville, ON
Associate Professor, Daphne Cockwell School of Nursing, Ryerson University, Toronto, ON
Hamilton, ON
Junior Faculty, CHSRF/CIHR Chair Program in APN
McMaster University
Hamilton, ON
St-Jrme, QC
Hamilton, ON
Introduction
Education is essential for securing the future supply of advanced practice nurses
(APNs) and for the continued development of those already in the workforce. In
Canada, education programs for clinical nurse specialist (CNS) and nurse prac-
titioner (NP) roles began 40 years ago. NPs are registered nurses with additional
educational preparation and experience who possess and demonstrate the compe-
tencies to autonomously diagnose, order and interpret diagnostic tests, prescribe
pharmaceuticals and perform specific procedures within their legislated scope
of practice (Canadian Nurses Association [CNA] 2008: 16). The CNA defines a
CNS as a registered nurse who holds a masters or doctoral degree in nursing and
expertise in a clinical nursing specialty (CNA 2009: 1).
Both national and international organizations have endorsed graduate educa-
tion as the entry to practice for APNs (CNA 2008; International Council of
Nurses [ICN] 2008). Education was one of the key components examined by the
Canadian Nurse Practitioner Initiative (CNPI), a two-year Health Canada-funded
project created to develop a framework for the integration and sustainability of the
NP role. Programs for CNS and acute care nurse practitioner (ACNP), also known
as NP (adult), NP (pediatrics) and NP (neonatal), education are uniformly at the
graduate level across Canada. Though in transition, education for the primary
Abstract
In Canada, education programs for the clinical nurse specialist (CNS) and nurse prac-
titioner (NP) roles began 40 years ago. NP programs are offered in almost all prov-
inces. Education for the CNS role has occurred through graduate nursing programs
generically defined as providing preparation for advanced nursing practice. For
this paper, we drew on pertinent sections of a scoping review of the literature and
key informant interviews conducted for a decision support synthesis on advanced
practice nursing to describe the following: (1) history of advanced practice nurs-
ing education in Canada, (2) current status of advanced practice nursing education
in Canada, (3) curriculum issues, (4) interprofessional education, (5) resources
for education and (6) continuing education. Although national frameworks defin-
ing advanced nursing practice and NP competencies provide some direction for
education programs, Canada does not have countrywide standards of education for
either the NP or CNS role. Inconsistency in the educational requirements for primary
healthcare NPs continues to cause significant problems and interferes with inter-
jurisdictional licensing portability. For both CNSs and NPs, there can be a mismatch
between a generalized education and specialized practice. The value of interprofes-
sional education in facilitating effective teamwork is emphasized. Recommendations
for future directions for advanced practice nursing education are offered.
healthcare nurse practitioner (PHCNP), also known as the NP (family/all-ages)
role, currently includes post-baccalaureate and masters programs (Canadian
Association of Schools of Nursing [CASN] 2004; Rutherford and Rutherford
Consulting Group Inc. 2005). Since the NP is a separately legislated role, education
programs require regular formal approval by provincial and territorial regulatory
nursing organizations. Matters pertaining to NP education, along with other issues
relevant to graduate education, are discussed annually at the Canadian Association
of Schools of Nursing Graduate Program Coordinators Forum during the
Associations conference. In follow-up to the report from the CNPI, NP educators
from across the country signalled their desire for a national forum to address issues
of importance to NP education. Two meetings have been held, and a national list-
serv was established through the Canadian Association of Schools of Nursing.
According to the CNA (2009: 2), universities are responsible for preparing CNS
roles by providing curricula based on the competencies of advanced nursing
practice and by developing innovative programs that facilitate access to graduate
education. The CNAs Advanced Nursing Practice Framework (2008: 14) identi-
fies that graduate credentials alone do not equate with advanced nursing practice
and that It is the combination of graduate education and clinical experience that
allows nurses to develop the competencies required in advanced nursing practice.
Some Canadian graduate nursing programs include courses in a clinical nursing
focus, for example, family, adult, community and mental health. However, while
many universities identify that their masters program provides preparation for
advanced nursing practice, none have a specifically titled CNS program and, with
one exception, do not have specifically titled CNS courses (Personal commu-
nication with 27 of 31 universities March 2010). For example, the University of
Manitoba offers a Master of Nursing with a cancer focus for advanced practice
nurse roles (University of Manitoba Faculty of Nursing 2009).
The aim of this paper is to provide a critical analysis of current advanced prac-
tice nursing education in Canada with a view toward what will be needed in the
future. We briefly summarize the history of CNS and NP education and examine
the current status of education for these roles in relation to curriculum, inter-
professional education, resources and continuing education. We conclude with
recommendations to promote advanced practice education in Canada.
Methods
This paper was developed using the results of the scoping review of the literature
and key informant and focus group interviews conducted for a decision support
synthesis commissioned by the Canadian Health Services Research Foundation
(CHSRF) and the Office of Nursing Policy in Health Canada (DiCenso et al.
2010a). The objective was to develop a better understanding of advanced practice
nursing roles, their current use, and the individual, organizational and health
system factors that influence their effective development and integration in the
Canadian healthcare system. The synthesis methods included a comprehensive
appraisal of published and grey literature on Canadian advanced practice nursing
ever published, as well as international literature reviews from 2003 to 2008. After
all levels of review, 322 papers representing all Canadian papers (69% of 468) and
recent reviews from other countries were retained in the synthesis. The 62 individ-
ual interview participants included 22 APNs, 11 health administrators, 6 provin-
cial government policy makers, 7 nursing regulators, 5 educators, 7 physicians and
4 healthcare team members. Four focus groups were held and attended by a total
of 19 participants, who were APNs, educators, administrators and policy makers.
A complete description of our methods is provided in an earlier paper in this issue
(DiCenso et al. 2010b). For this paper, we focus on articles and key informant
interviews that address education.
Results
History of Advanced Practice Nursing Education in Canada
The first Canadian education program for NPs, the Outpost Nursing Program,
was initiated in 1967 and offered at Dalhousie University in Halifax until 1997.
Its emphasis was on preparation for primary healthcare practice in remote
communities (Chaytor Educational Services 1994; Haines 1993; Martin-Misener
et al. 1999). Programs at McMaster University in Ontario and in other provinces
followed quickly thereafter (Haines 1993; Herbert and Little 1983; Kergin et al.
1973). These early programs were housed in universities and offered post-diploma
or post-baccalaureate preparation for what was often referred to as the expanded
role of the nurse and family practice nursing (Advisory Committee on Health
Human Resources et al. 2001; Chambers et al. 1974; Jones and Parker 1974; Riley
1974). The McMaster University PHCNP initiative included a program of research
to evaluate the NP training and role (Kaasalainen et al. 2010). Despite evidence
of the programs success in preparing safe and effective NPs, funding for the
education and employment of NPs in all but remote areas virtually disappeared
once the physician shortage was resolved (Spitzer 1984). In the 1990s, however,
cutbacks in medical residency positions along with a healthcare reform agenda
focused on fiscal efficiency and a shift toward community-based care brought
renewed government interest in the NP role and funding for NP education in
some provinces (DiCenso et al. 2007).
The Council of Ontario University Programs in Nursing (COUPN), a consortium
of 10 nursing faculties, developed the COUPN PHCNP Program, which began
in the fall of 1995 (Andrusyszyn 1999; Cragg et al. 2003; DiCenso et al. 2003; van
Soeren et al. 2000). Funding for the program was provided by the Ontario govern-
ment and came with a requirement that the program be offered at the post-
baccalaureate level. The curriculum was developed and offered jointly by 10
schools in French and English, full-time and part-time, distance and on-site, in
post-baccalaureate certificate and post-RN baccalaureate programs. These charac-
teristics make it a unique model of NP education in Canada.
The COUPN PHCNP Program was extensively evaluated soon after it began
(DiCenso et al. 1997, 1998). The outcome component of the evaluation used a
before-after study design with first-year students and program graduates to deter-
mine knowledge acquisition in the program. A cohort study compared the knowl-
edge, problem-solving and clinical skills of NP program graduates with second-
year family medicine residents. Knowledge was evaluated using a multiple choice
examination, problem solving using the College of Nurses of Ontarios Case
Assessment Tool (written case-based short answer test), and clinical skills using six
simulated patient scenarios scored by physician-NP teams with controls in place
to detect examiner bias.
The study investigators found that NP program graduates knowledge scores were
significantly higher than those of first-year NP students. There was no statistical
difference between the NP and resident groups for questions related to obstetrics/
gynecology, psychiatry, prescribing, vaccines/immunization and prevention/health
promotion. However, the resident group scored higher than the NP group on
medicine and pediatric questions. With respect to problem solving, there was no
difference in overall scoring between the two groups; however, the residents scored
higher than the NP graduates in health assessment and diagnosis, and the NP grad-
uates scored higher than the residents in health promotion and disease prevention.
In terms of clinical skills evaluation, the NP group scored similarly to the family
medicine resident group in all six simulated patient scenarios and in interviewing,
history taking, counselling, management and physical examination skills.
Soon after the COUPN NP Program was established, other programs followed suit
in almost every province. Some programs were initiated at the post-diploma level,
some at the post-baccalaureate level and others at the masters level (Rutherford
and Rutherford Consulting Group Inc. 2005).
The first ACNP education programs were initiated during the 1980s and 1990s
and, in contrast to PHCNP programs, all began at the graduate level (Alcock
1996; Dunn and Nicklin 1995; Haddad 1992). The first ACNP program, designed
to train neonatal nurse practitioners, was first offered at McMaster University in
1986. Program development was guided by the results of an interprofessional role
definition study (Hunsberger et al. 1992). The educational program was evaluated
extensively, both in the form of a before-after study (Mitchell et al. 1995) to ensure
that those completing the program had acquired the expected competencies in
knowledge, problem-solving, communication and clinical skills and in the form of
a cohort study (Mitchell et al. 1991) to compare the skills of graduating neonatal
NPs with those of pediatric residents.
Recently released statistics from the Canadian Institute for Health Information
(CIHI) (2010) show that in 2008, there were 1,626 licensed NPs in Canada. These
data do not distinguish between PHCNPs and ACNPs. Of the 1,626 NPs, 597
(36.7%) had obtained a masters or doctoral degree as their highest education in
nursing, 834 (51.3%) had a baccalaureate degree and 195 (12%) had a diploma.
Compared to the registered nurse workforce, the proportion of NPs with a gradu-
ate degree is more than 10 times higher (36.7% versus 3.0%).
The CNS role emerged in Canada and the United States in response to post
World War II employment and education opportunities (Boone and Kikuchi, as
cited in Montemuro 1987). From its inception, graduate education was required
for the CNS role and articulated as such in the position statements of profes-
sional nursing organizations (Alcock 1996; Montemuro 1987). Although it was
not specifically developed to educate CNSs, the first Canadian program offering
clinical nursing specialization was the University of Toronto in 1970 (Montemuro
1987). There are limited data about CNSs in Canada (Bryant-Lukosius et al. 2010).
Current Status of Advanced Practice Nursing Education in Canada
While Canada does not have country-wide standards of education for either the
NP or CNS role, two national consensus frameworks of importance to education
have been developed: the CNAs Advanced Nursing Practice: A National Framework
(2008) and the Canadian Nurse Practitioner Core Competency Framework (CNA
2005). Both provide guidance to the curricula of advanced practice nursing
educational programs. Data collected by CNPI provided a comparative analysis
of PHCNP and ACNP programs offered in Canadian educational institutions in
2005 (CNPI 2006). At the time, 25 NP programs were offered by 33 educational
institutions; of these 25 programs, 13 trained PHCNPs, 9 trained ACNPs and
3 combined PHCNP and ACNP training. Exit credentials from these programs
included a post-RN certificate/diploma (n = 3), post-baccalaureate certificate/
diploma (n = 2), masters (n = 15), masters or post-masters diploma/certificate
(n = 4) and post-masters certificate (n = 1). The greatest variability was and
continues to be in PHCNP programs.
Realizing the masters degree as the exit credential for PHCNP education has been
challenging, though some progress has been made. Barriers have included the
reluctance of some governments to fund NP programs at the masters level and
the reluctance of institutions without graduate programs to be excluded from
offering NP education (Cragg et al. 2003). Nevertheless, the recent Canadian
nursing literature resounded with the strong endorsement that graduate educa-
tion was needed to achieve the broad theoretical and clinical knowledge and skill
requirements of advanced practice nursing roles and should be the entry to prac-
tice requirement (CNA 2008; CNPI 2006; Schreiber et al. 2005a, 2005b). Based
on their interviews with graduate prepared nurses when investigating the current
understanding of and perceived need for advanced practice nursing in British
Columbia, Schreiber et al. (2005a: 14) suggested that graduate preparation itself
contributes to the ability to analyze and practice in complex situations at a sophis-
ticated level. In a second phase of the same qualitative study, participants from
diverse stakeholder groups including physicians concluded the complexity of the
work required of PHCNPs warranted graduate education (Schreiber et al. 2005b).
Similarly, a qualitative study from Australia concluded graduate education was
needed for NPs to meet the demands of the role and foster the credibility of their
preparedness for the role (Gardner et al. 2006).
Interview participants in our synthesis differed in their views about the educa-
tional requirements for PHCNPs. An APN participant explained how the knowl-
edge acquired during graduate education enables NPs to practise autonomously
and to offer comprehensive patient care services in this way:
I have worked with very many of the nurse practitioners who are
advanced certificate-prepared and theyre good, but it only extends to
a certain role, basically very much focused on the diagnosis and treat-
ment. When you get into the true population health community devel-
opment perspective, they lack. What the masters brings to people is
the complete picture. Ive noticed sitting in with a few different nurse
practitioners when I was doing my own education to see the difference,
and I saw a total difference between a masters-prepared and a certificate-
prepared [NP] just in how they approached it, the completeness they
brought to the interaction with the patient and the follow-ups.
Many educator, regulator and administrator participants and some govern-
ment participants talked about the legitimacy and credibility graduate education
provides. Some linked graduate education with the ability to practise autono-
mously with a broad scope of practice. The following quote illustrates this.
Primary care is clearly recognized across the country as a significant prob-
lem. So on the advice of many we positioned our primary care nurse
practitioners to have a very wide prescriptive and diagnostic authority,
which meant they had to have a really rigorous education program at the
masters level.
In contrast, other interview participants indicated that the push to move PHCNP
education to the masters level was misguided. Although intended to benefit NPs,
it was unlikely to improve patient care or healthcare system efficiency. Some
government informants stated they did not support graduate education for
PHCNPs because it was unjustified by evidence. The longer program reduced the
number of NPs in the system, and the higher tuition costs were likely to lead to
higher salary demands by NPs, without concomitant increases in their accessibility
and number of patients served.
While not arguing against graduate education, several authors (CNPI 2006;
Schreiber et al. 2005a, 2005b) identified that the requirement of graduate educa-
tion for PHCNPs was a concern for northern jurisdictions because of the
limited access to graduate education in rural and remote communities. This is
an important concern since only 5.9% of all registered nurses practising in rural
and remote areas are APNs (Stewart et al. 2005). Although masters NP program-
ming is available by distance education from several universities, accessibility has
been confounded by other factors such as competing demands in the workplace,
technological challenges and other difficulties related to geographical remote-
ness (CNPI 2006; Tilleczek et al. 2005). Our interview participants also identified
the importance of distance education for both CNS and NP roles, explaining
that family and financial obligations limited their mobility, and voiced similar
concerns about the accessibility of educational programs. Despite these challenges,
some northern jurisdictions indicated they envisioned having at least one PHCNP
in each remote community by 2010 (Northwest Territories Health and Social
Services 2004). In addition to distance education, another strategy some north-
ern educational institutions are using is to forge collaborations with universities
to enable masters level PHCNP education to be offered using a combination of
face-to-face and distance modalities (Registered Nurses Association of Northwest
Territories and Nunavut 2009).
Regulators, educators and government informants in our synthesis reported
that inconsistency in educational requirements was continuing to cause signifi-
cant problems, especially when education was tied to licensing. For example,
NPs educated at the post-baccalaureate level were not able to become licensed in
British Columbia or Quebec. Several interview participants referred to imminent
changes through the Agreement of Internal Trade that would enable NP mobil-
ity across Canadian jurisdictions by prohibiting discrimination on the basis of
educational preparation. For the most part, this was regarded as positive for NPs,
although some interview participants were concerned about the potential out-
migration of NPs from provinces that paid lower salaries.
A review from the United States indicated CNS programs there are expanding
(Fulton and Baldwin 2004). In our study, CNS education was discussed most
often by APN interview participants. The following quotes from three APNs
from different provinces convey concerns about the absence of programs specific
to the CNS role.
I have concerns at the education level about how CNSs are being able to
access their education. [University] masters program used to have a CNS
role. Now they have one course on advanced practice. They have a whole
NP program, but if you want to become a CNS its becoming more and
more difficult to get that kind of system-thinking, system-support level of
education to be able to understand where your role is at the systems level.
Well, my understanding is that there arent that many masters programs
that have a CNS stream. Now theyre being developed as an advanced prac-
tice nursing role thats the stream. Its [CNS] no longer a clinical specialty
that you develop at the masters level of preparation and thats unfortunate.
The key concern around the CNS role which is of grave concern to me is
the lack of specific education for the CNS role. There used to be programs
that had a very well designed course content that would prepare them for
evaluation, for project management, for the whole piece of work at the
systems level, policy, developing policy and protocols. All of those pieces
are not necessarily lumped together in a nice package so that when you
come out you can really step out in the role and fly, and in the United
States there are some of those educational programs directed for the CNS.
There were in Canada, but there arent anymore.
One educator interview participant indicated that progress toward development
of a CNS educational stream was being made at one Canadian university. The
following quote describes this innovation and how program developers have
distinguished CNS and NP education.
Weve had various meetings with the CNS community to work with them
to be part of the educational programs. Weve ramped up. Weve actu-
ally changed some of our core courses from advanced practice nursing
courses to CNS courses. Weve done lots of marketing to help nurses make
distinctions. Weve held information nights to help potential candidates
make distinctions between how they might choose what sort of role
they were going for. We do it in a visual image that shows a triangle with
system knowledge and research inquiry and direct patient care skills and
[we] really demonstrate that this pyramid, this triangle, is diametrically
opposite. What a CNS [and NP] learn. The thing at the top of the pyra-
mid of the one is at the bottom of the pyramid for the other, and vice
versa. So that educationally they are very differently prepared and the
roles that theyre going to take are very different.
Curriculum Issues
A number of papers identified a need for national curriculum standards and a
consistent core curriculum for both NP and CNS programs (CASN 2004; CNA
2006, 2008; CNPI 2006; Olson 2004; Schreiber et al. 2005a). The rationale for
improved consistency, coherence and alignment of educational programs was to
enhance the credibility and visibility of NP and CNS roles, improve their integra-
tion into healthcare systems, facilitate better use of NP and CNS resources and
enable labour mobility. Many interview participants echoed this, as reflected in
the following comment from an administrator.
There probably needs to be a national standardization, or some sort of
process to look at accreditation, standardization of programs.
Other participants signalled their caution that curriculum standardization should
not be so rigid that it impeded creativity and innovation. As one American educa-
tor commented,
CNS education is pretty diverse and needs to come together a little bit more
around what are the standards for educating CNSs. Where in my opinion,
as an educator, the nurse practitioners stuff is too contrived, it is lock step
standard curriculum. You need curricular standards; you dont need a
standardized curriculum. It makes it hard to try and change, to be able to
adapt and adjust, if youve locked yourself in to a standardized curriculum.
The CNPIs (2006) review of the curricula of NP programs across Canada identi-
fied some commonalities in the types of courses that were included, such as health
assessment, pathophysiology and management of health and disease, including
prescribing. It did not assess differences or commonalities in the content or meth-
ods of appraisal used in these courses. The CNPI review reported inconsistencies
among educational programs in the types of core graduate theoretical courses
being offered, the balance between theory and clinical experience, and program
length. Differences in program length were attributed to whether the program
was a masters or not, the former being consistently two years in length and the
latter 12 months. A recent review of the university calendars of 24 Canadian
masters nursing programs found the number of research course requirements
ranged from one to three, and one program had no mandatory research course
(J. Ritchie, personal communication, March 23, 2009). In some programs the
number of required research courses varied according to thesis, course-based and
NP streams. This review did not include a comparison of curriculum content
related to the leadership, consultation, collaboration and education components
of advanced practice nursing.
Making decisions about what to include in education programs for entry level
practice and, more importantly, what to leave out, has been a long-standing chal-
lenge (Martin-Misener et al. 1999). Our interview participants suggested the addi-
tion of a variety of topics to the curricula, such as more in-depth pathophysiology,
conflict resolution, APN-physician collaboration, government lobbying, political
navigation, writing job descriptions and a final formal residency or internship.
At the same time, as reflected in the following quotes from an administrator and
APN, they expressed concerns about program length and the balance between
clinical experience and theory.
Education was viewed as a long process that may not meet the needs of
the work setting where a large number of credits were related to research
and less on the actual role in the setting.
Nothing is long enough, if you want to learn everything, and some things
are too long, students will tell you.
Although there was support for the distinctiveness of CNS and NP roles
(Urquhart et al. 2004) and the importance of having a match between advanced
practice nursing education and role expectations in the practice setting (Roots
and MacDonald 2008), the Canadian literature was silent on the debate about
the merits or lack thereof of a shared curriculum for different types of APNs. The
literature from the United States highlighted some commonalities in the CNS
and NP roles, but reflected divergent perspectives about whether a shared educa-
tional curriculum was desirable (Carper and Haas 2006; Chan and Garbez 2006;
Goudreau et al. 2007; Stark 2006).
The comments from our interview participants supported a need for educational
curricula specific for CNS, ACNP and PHCNP roles. Educator and physician
participants commented on the limited availability of NP programs in some parts
of the country, resulting in situations where NPs educated for primary healthcare
were employed and expected to have the skill set to practise in a specialized ACNP
role. The result was not that great of a fit. Government participants from differ-
ent provinces added that inadequate communication about NP roles and compe-
tencies contributed to the discordance between education and ACNP positions.
A similar problem was identified about the CNS role by ACNP and administra-
tor participants. They commented that CNSs obtain generic masters degrees in
nursing but practise with specialized populations without a certification process
or protected titling. Consequently, there are a number of nurses prepared at the
graduate level with clinical specialization who address the components of the CNS
role and yet are not titled CNS. At the same time, as the following quote illustrates,
the lack of precision in the education and titling of CNSs means that anyone with
a masters degree in nursing can claim to be a CNS.
They think that just because they have a masters degree means they can be
a CNS. And so that is a problem within all of the nursing community. Nurse
practitioner education is very specific you graduate with your NP.... As a
CNS, its not that specific. What is the education for a CNS? I dont know.
How do you get to be a CNS? Lots of people would say, I dont know.
Thus both the non-CNS titled nurse in the role of a CNS, and the indiscriminate
use of the CNS title, contribute to role confusion within and outside the profes-
sion. Improvements are needed in how the role is described and how the title is
controlled (Bryant-Lukosius et al. 2010).
Interprofessional Education
The value of interprofessional education in facilitating effective teamwork was
a consistent theme in the literature (Barrett et al. 2007; Jones and Way 2004; van
Soeren et al. 2007). It is supported by both nursing and medical associations
(Canadian Medical Protective Association and Canadian Nurse Protective Society
2005; CNA 2003; Ontario Medical Association and Registered Nurses Association
of Ontario 2003) and educational institutions (CASN 2004; Pringle et al. 2000).
Writing specifically about NPs and physicians, Bailey et al. (2006) identified syner-
gistic decision making and bi-directional consultation and referral as hallmarks
of optimal collaboration but acknowledged collaboration of this calibre was not
easily achieved, even with education. They recommended more research to under-
stand the effectiveness of education interventions.
Many interview participants also spoke of the importance of interprofessional
education. They identified a need for more interprofessional learning opportu-
nities among health disciplines, commenting that students need to be learning
together. The following quotes from an administrator and educator emphasize
the value of interprofessional education to enable advanced practice nursing and
other health professional students to learn about and trust in the capabilities of
each others roles.
I think within the healthcare system just educating about the role as part
of the clinical education process and trying to ensure that physicians and
others have an opportunity to have interprofessional placement opportu-
nities as part of their education would be a critical factor.
I think if there was more interprofessional education so that there was
a better understanding of who does what, how and why and trust in it
[interprofessional collaboration would improve]. Part of this is about
trust that they really know what they are doing. You could do this with
some of the physical assessment stuff; there are ways you could thread
things through common shared knowledge.
Resources for Education
The literature (Cross and Goodyear 2004; Cummings and McLennan 2005;
Lachance 2005) and key informants concurred that funding for advanced practice
nursing education was insufficient, resulting in implications for students, faculty
and programming. Educators and administrators expressed concern over the cost
of NP education and low earning potential of NPs in some jurisdictions, explain-
ing that it could create recruitment challenges. Physician, regulator and adminis-
trator participants recommended support in the form of student bursaries; some
indicated NP students were already being supported financially.
The need for funding to develop faculty, preceptors and mentors to teach advanced
practice nursing students and to support role socialization was stressed in the liter-
ature (CNPI 2006; Goudreau et al. 2007; Schreiber et al. 2003; 2005a; van Soeren
et al. 2007). Competition for clinical placements and physician time to train both
medical residents and ACNPs was another concern (Fdration des mdecins rsi-
dents du Qubec 2004). We found one Canadian study that evaluated NP educa-
tion from a cost perspective. Kushner (1976) reported on the economic returns of
the McMaster University program, concluding that NP education was profitable
from the point of view of the student since costs were recuperated within two years
of program completion. The introduction of NPs was desirable from a societal
point of view in that the rate of return on the investment in the program exceeded
the rate of social discount, and the investment was profitable to the government if
the NP stayed in the workforce 30 years (Kushner 1976).
Many of our interview participants expressed concerns about whether clini-
cal placement sites would be able to support the learning needs of all the vari-
ous types of students who require this experience as part of their educational
program. They indicated that there was already competition for clinical place-
ments and expected this to be exacerbated by increasing numbers and types of
students. Participants called for better mentorship opportunities for advanced
practice nursing students and stressed the importance of having academically and
clinically qualified faculty and preceptors. Many indicated a need to recruit more
faculty and strategic planning to ensure a supply of qualified faculty to meet the
needs of advanced practice nursing programs.
Interview participants did not comment specifically on the cost of education,
except to acknowledge it was resource intensive. Some participants recommended
sharing academic resources across universities throughout the country, as well as
intra-university sharing among the various health disciplines. The following quote
offered by an educator exemplifies this idea.
Were looking at a limited number of graduate students and limited
numbers of faculty, and so I think there may be ways to deliver some of
the programs in different ways and I think there needs to be cooperation
across the country.
Continuing Education
The importance of ongoing learning and removal of barriers to continuing educa-
tion for NPs was evident in the Canadian literature (CNPI 2006; Donald et al.
2009). The lack of opportunity for relevant continuing education was a challenge
for NPs in long-term care (Stolee et al. 2006) and remote settings (Martin-Misener
et al. 2008). Tilleczek et al. (2005) found face-to-face learning venues were valued
by all NPs, but rural and northern NPs found distance modalities useful because
of travel and distance constraints. Other barriers to continuing education were
difficulty taking time off work, insufficient resources, family responsibilities, lack
of information regarding the availability of courses, geographical barriers, fatigue,
unsatisfactory previous learning experiences (Centre for Rural and Northern
Health Research 2006) and the lack of faculty (Schreiber et al. 2003, 2005a).
Interview participants echoed findings from the literature commenting on both
the importance of continuing education and barriers to it, as the following quote
from a physician demonstrates.
Our APNs need more attention paid, in my opinion, to their continuing
professional development their ongoing education. I mean thats impor-
tant for all healthcare personnel, but its especially important for these
people. Most often theyre in leadership positions either because its written
down on paper or simply because they command the leadership because of
their abilities. It is important that they keep up with what is going on.
Educator interview participants added that lack of funding impeded their delivery
of continuing education. Regulator interview participants supported a compre-
hensive plan for continuing education for APNs and called attention to the need
for additional education for NPs who provide care for patients with urgent and
emergent conditions in remote settings, where there are few resources. CNS
interview participants advocated for improved continuing education for CNSs in
remote settings, highlighting it as a retention strategy.
Discussion
Canada is not unique in its struggle to move forward with advanced practice
nursing roles and education reforms. Worldwide, countries are endeavour-
ing to define NP roles and establish educational standards (ICN 2008; Royal
College of Nursing 2008; Sheer and Wong 2008). Justifying the need for
advanced education for the PHCNP role is a recurrent challenge (Gardner et
al. 2006). Globally, nursing organizations have recommended that the educa-
tional standard for APNs be a graduate degree (Pulcini et al. 2010). While
there has been some progress toward attaining this goal in Canada, discrep-
ancies persist in the educational requirements for PHCNPs. Two provinces
(Newfoundland and Labrador, and Saskatchewan) continue to offer PHCNP
education programs at less than a graduate level. While Ontario has prepared
PHCNPs at the post-baccalaureate level for many years, this is in transi-
tion with all universities that offer PHCNP education now offering graduate
courses. Given this, it is unlikely that Canada will realize masters education
for all APNs by the close of 2010, as the CNPI hoped; perhaps the fallback
goal of 2015 will be achieved.
Furthermore, the quest to realize masters education for all NPs is occurring
in a context in which most other disciplines in the health professions have
established a masters or doctorate degree as their requirement for entry
to practice. Just to the south, in the United States, the doctorate of nursing
practice (DNP) will become the entry level credential for APNs by 2015.
The DNP differs from a PhD in that its focus is advanced clinical education,
whereas the focus of a PhD is advanced research preparation. The discussion
about the advantages and disadvantages of DNP education for the Canadian
context has begun (Acorn et al. 2009; Joachim 2008; Nelson 2008). However,
given that masters level preparation for all NPs in Canada has yet to be
achieved, it is difficult to see how a case for doctoral preparation could be
argued convincingly or successfully at the present time.
Clearly there are still significant challenges to overcome. Governments
persistently demand evidence to support the need for higher education
for PHCNPs and so far have not been convinced by the consensus-based
expert opinion studies that exist. There are also concerns that higher train-
ing requirements will increase the expense, and reduce the health human
resource benefit, of NPs when regarded as substitutive healthcare profession-
als (Evans et al. 2010).
Our scoping review and key informant interviews identified a number of
issues related to advanced practice nursing program access and curricula.
There is a tension between the length of advanced practice nursing programs
and the development of the full range of advanced practice nursing compe-
tencies clinical, research, leadership, consultation and collaboration
(CNA 2008). According to the CNAs Advanced Nursing Practice: A National
Framework (2008: 23) generating, synthesizing and using research evidence
is central to advanced nursing practice, and APNs are able to as either
primary investigator or collaborator with other members of the healthcare
team or community, identify, conduct and support research that enhances or
benefits nursing practice. Despite these aims, APNs consistently report that
research is the most underdeveloped aspect of their role (Bryant-Lukosius et
al. 2004, 2007). The findings from our study raise questions about what the
research content of an advanced practice nursing curriculum should include
and whether it should be the same for all advanced practice nursing roles.
In addition, while there is clear support for inter-professional education,
the knowledge base that underpins and guides the best practices for inter-
professional education in advanced practice nursing education requires
further development. As the evidence base of pedagogical effectiveness
expands, advanced practice nursing curricula will need to respond accord-
ingly. This and the push for increased efficiencies in education, accessible
distance education opportunities and improved clinical training for APNs
will challenge the creativity and flexibility of program planners.
Another important finding of our synthesis was that for both CNSs and NPs,
there can be a mismatch between a generalized education and specialized
practice. Universities in the United States offer specialty and subspecialty
education during entry level masters programs (Richmond and Becker
2005). It is unclear how much specialty education a country the size of
Canada, with its relatively small number of APNs can support, especially
since specialty education requires substantial resources not only at the
university level but also for credentialling and certification (CNA 2006;
CNPI 2006). The Canadian examinations for NPs, which many provinces
and territories have incorporated into their licensing processes, include
family/all ages (primary healthcare), adults, pediatrics and neonatal. While
primary healthcare and neonatal are defined specialized areas of practice,
adult and pediatric descriptors are broader.
Still, creative solutions to the challenge of access to specialty education have
emerged that may have wider application. For instance, the consortium
distance model to education used by COUPN has proven to be an effective
approach to PHCNP education in Ontario (Andrusyszyn et al. 1999; Baxter
et al. 2009; Cragg et al. 2003; van Soeren et al. 2000, 2003). Such a model
could be adapted and applied to address other education needs including
specialization. Another example of a partnership approach is the special-
ized interprofessional psychosocial oncology education courses offered to a
national audience by faculty from multiple institutions using distance tech-
nology (www.ipode.ca). This model is particularly attractive from a cost-
effectiveness perspective when the specialty area is small and could poten-
tially be replicated for other specialties.
For the time being, the limited access to specialty education in Canada
means that NPs and CNSs may be working in clinical areas in which they
initially do not have specialized knowledge and skills. Given this reality,
mentorship is a role development support that could be further exploited to
enhance specialized knowledge acquisition. The Ontario oncology advanced
practice nursing mentorship program is an example of an interprofessional
mentorship program accessible by distance modalities throughout Ontario
(http://apn.webexone.com/login.asp?loc=&link). Continuing education is
another means of enabling APNs to develop and maintain specialist knowl-
edge and stay up-to-date with current evidence-informed practice. However,
attention to the barriers associated with the delivery of and accessibility to
continuing education for APNs is needed.
A multidisciplinary roundtable convened by CHSRF formulated evidence-
informed policy and practice recommendations based on the synthesis
findings. All of their recommendations are reported in an earlier paper in
this issue (DiCenso et al. 2010b). Specifically pertinent to advanced practice
nursing education are the following: (1) a pan-Canadian approach should
be taken to standardize advanced practice nursing educational standards,
requirements and processes, and (2) the curricula across all health profes-
sions should address interprofessionalism (DiCenso et al. 2010b). These
recommendations mirror those of the CNPI (2006) and resemble those of
American scholars who have argued for reforms that will lead to standardi-
zation of education programs and accreditation or other regular review
processes (Hanson and Hamric 2003; Olson 2004). The most convincing
argument for moving forward on these recommendations is the potential
impact it could have on patient care. We need to be able to determine and
provide the best possible education for the various types of advanced prac-
tice nursing roles so that these roles can best meet the needs of patients and
healthcare organizations (Bryant-Lukosius and DiCenso 2004).
The environment in which all of these changes and challenges are happen-
ing is fiscally constrained. That said, an ongoing supply of qualified faculty,
preceptors and appropriate clinical placements is essential for Canadian
programs to educate safe, competent practitioners. These are scarce resources
and careful planning is needed to ensure there will be sufficient numbers
to meet the learning needs of future generations of APNs. For students, the
high cost of education, especially in lengthy programs, may affect recruit-
ment and retention, particularly when taking into account lost salary and
unattractive earnings post-graduation. Provincial and territorial financial
support for advanced practice nursing programs varies across the country,
though our synthesis did not investigate this specifically. Comparisons of the
financial support for the education of various health professionals, particu-
larly newly introduced professionals, are not available. Such information
could be useful for determining the equity of funding across programs.
How then should we move forward on the findings of the synthesis and
CHSRF roundtable recommendations? The CNPI was an extraordinary pan-
Canadian example of what can be accomplished when the combined efforts
of multiple sectors, resources and champions use a systematic, evidence-
based approach to achieve a common goal. Surely the way forward is to find
a way to build on this model. Because leadership in nursing education is the
mandate of the Canadian Association of Schools of Nursing, this organiza-
tion is well positioned to take the initiative to move this agenda forward
in partnership with other national organizations such as the Canadian
Association of Advanced Practice Nurses, the CNA and the Office of Nursing
Policy, as well as provincial regulatory bodies and academic institutions.
Further development of advanced practice nursing education is critical for
ensuring that Canadians nationwide receive accessible healthcare of the
highest quality. We know what needs to be done. The time has come for all
of us to step up to the plate and make it happen.
Acknowledgements
and Brandi Wasyluk. Special thanks go to our advisory board, roundtable partici-
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85
COMMENTARY
This timely paper provides a thought-provoking analysis of current advanced prac-
tice nursing education in Canada. It comes at a critical juncture in the evolution
of Canadian healthcare services and the redefinition of nursing roles. Increasingly,
multiple sectors of society are calling for more nurses with advanced practice
preparation and for a wider range of advanced practice nursing specialties.
Advanced practice nurses (APNs) are being proposed as a solution to a financially
overburdened national healthcare system, the increasing complexity of healthcare
services, and a crisis in access to primary healthcare. Thus, governments seeking
greater fiscal efficiency, medical specialists needing sophisticated collaborative
support, and healthcare consumers see APNs as the way forward.
As is often the case with social change, and as the authors of the article demon-
strate, there was no master professional plan underpinning the introduction of
advanced nursing practice or education. There was also no overarching profes-
sional vision of how responsibilities associated with advanced practice nursing
should be organized into subgroups. Instead, the historical analysis demonstrates
that educational programs were developed ad hoc by individual schools or a
consortium of schools in response to specific health needs of service institu-
tions or regional communities, typically at the request of government and often
before the roles had been created in the healthcare system. Thus, the curricula and
program goals were introduced in an ad hoc fashion across the country to address
local or regional health service needs rather than to prepare learners for profes-
sional practice as defined by the profession or its representative associations.
Advancing the Educational Agenda
Cynthia Baker, RN, PhD
Executive Director, Canadian Association of Schools of Nursing
Given the discursive path of the introduction of advanced practice nursing, as well
as the provincial/territorial control of health and education, it is not surprising
that Canada lacked nationwide standards for both nurse practitioner and clini-
cal nurse specialist roles However, two significant advances have addressed this
issue. The authors point out the importance of the publication of the Canadian
Nurse Practitioner Core Competency Framework (Canadian Nurses Association
[CNA] 2005) and Advanced Nursing Practice: A National Framework (CNA 2008).
These documents provide a national consensus on APNs roles and responsibili-
ties. Additionally, the authors note that many provincial regulatory bodies now
include the Canadian national entry to practice exam for nurse practitioners in
their licensing processes. This exam follows the National Framework of Nurse
Practitioner roles and encompasses family/all ages (primary healthcare), adults,
paediatrics and neonatal. Thus, the profession has moved forward to a national
conceptualisation and classification of advanced practice roles, and a national
articulation of nurse practitioner competencies.
It is also not surprising that educational requirements for nurse practitioners are
inconsistent from one jurisdiction to another. While commonalities exist in the
curricula across the country, standards vary. The authors identify major discrep-
ancies in the level of preparation required, particularly in primary healthcare
nurse practitioner programs. To some extent this is related to the ad hoc introduc-
tion of the programs. The initial demand for nurse practitioners coincided with a
dearth of physicians in remote rural areas of the North. To fill the gap, nurses were
provided with additional post-registration or post-baccalaureate training to work
more autonomously. In southern Canada, with an oversupply of physicians at the
time, the situation was different. Acute care nurse practitioner programs at the
masters level were established in the eighties and nineties to prepare practitioners
for work in high-tech institutions in urban centres, where clinical nurse special-
ists were already employed and required a masters degree. The overwhelming
perception in the literature reviewed by the authors is that all advanced practice
nursing education should be at the masters level in Canada.
In contrast with nurse practitioners, the clinical nurse specialist has required a
masters degree since the inception of the role. There are no CNS titled programs,
however, and a lack of clarity regarding what type of masters degree programs
prepares one for the CNS role. In fact, holding a masters or doctoral degree in
nursing is part of the CNA definition of what a clinical nurse specialist is.
The article demonstrates a significant need for national educational require-
ments and quality indicators for advanced nursing educational programs in this
country. With the recent pan-Canadian articulation of advanced professional
practice, the resurgence of the CNS role in the United States, regulatory approval
87 Advancing the Educational Agenda
of nurse practitioner programs and a national entry to practice examination, a
solid foundation is in place for the elaboration of national educational standards.
It is clearly the moment in the evolution of Canadian advanced practice nursing
to develop a national educational framework that is aligned with, and reflective of,
the national vision for nurse practitioners and clinical nurse specialists.
The authors challenge the Canadian Association of Schools of Nurses (CASN) to
take the lead in advancing this educational agenda in partnership with organiza-
tions such as the Canadian Association of Advanced Practice Nurses (CAAPN),
the CNA and provincial/territorial regulatory bodies. CASN is strongly committed
to advancing the quality of educational programs for APNs across the country.
As a first step, following the approach of our sister organization the American
Association of Colleges of Nursing, a national task force with broad representation
is being set up to delineate the essential components of nurse practitioner educa-
tion in Canada for primary healthcare, adult, pediatric and neonatal programs. It
is important that a similar initiative follows with respect to the educational prepa-
ration of clinical nurse specialists.
The successful development of educational and practice standards involves the
engagement of professional associations, practice leaders and educators in a
complex, interactive, iterative and multilinear process. Despite the educational
inconsistencies identified in the article, this process has begun for advanced prac-
tice nursing education in Canada. CASNs aim, as the national voice of nursing
education, is to generate further momentum and take the process forward.
References
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88
The Primary Healthcare Nurse
Practitioner Role in Canada
Faith Donald, NP-PHC, PhD (co-lead author)
Toronto, ON
Ruth Martin-Misener, NP, PhD (co-lead author)
Halifax, NS
the Juravinski Cancer Centre at Hamilton Health Sciences
Hamilton, ON
St-Jrme, QC
Hamilton, ON
McMaster University
Hamilton, ON
Oakville, ON
Ivy Bourgeault, PhD
Abstract
Primary healthcare nurse practitioners (PHCNPs), also known as family or all-ages
nurse practitioners, are the fastest growing advanced practice nursing role in
Canada. All 10 provinces and three territories now have legislation that author-
izes their role. Their introduction is linked to countrywide health reform efforts to
improve the accessibility and quality of primary healthcare.
This paper focuses on the PHCNP role and draws on the results of a scoping review
of the literature and qualitative key informant interviews conducted for a deci-
sion support synthesis commissioned by the Canadian Health Services Research
Foundation and the Office of Nursing Policy in Health Canada. The overall objective
of this synthesis was to develop a better understanding of advanced practice nursing
roles and the factors that influence their effective development and integration in the
Canadian healthcare system.
Based on synthesis findings, we describe the current status of PHCNP roles in Canada
and describe three important challenges to their integration and long-term viability:
restrictive legislation and regulation, inconsistencies in educational preparation
across Canada and working relationships between PHCNPs and family physicians.
We conclude that although there has been considerable progress made in integrat-
ing PHCNPs into the Canadian healthcare system and there is mounting evidence to
support the value of the role, there is more to do to fully integrate and sustain the
role. A pan-Canadian approach is needed to the education, supply, legislation and
regulation of PHCNPs, as well as further dialogue at all levels to enhance how PHCNPs
and family physicians can work together to provide optimal primary healthcare.
Ottawa, ON
Hamilton, ON
Introduction
The predecessors of todays primary healthcare nurse practitioners (PHCNPs)
began their practice in the Canadian North more than 100 years ago. These early
PHCNPs, known most commonly as outpost nurses, were introduced by religious
organizations to improve primary healthcare services for underserviced popula-
tions (Graydon and Hendry 1977; Kaasalainen et al. 2010; Kulig et al. 2003).
It was not until the early 1970s, when the Canadian healthcare system was experi-
encing a shortage of family physicians, that the first wave of PHCNPs was intro-
duced in southern urban communities. National and provincial attention was
directed toward defining their role and scope of practice, determining education
standards and evaluating the effectiveness of the role (Kaasalainen et al. 2010).
PHCNPs provided expanded primary healthcare services to individuals and fami-
lies, mostly in family practice offices or community health centres (Kergin et al.
1973). Collaboration with family physicians and other healthcare team members
was an expectation of the PHCNP role and was integral to PHCNP role descrip-
tions. Despite the positive results of several randomized controlled trials evaluat-
ing the effectiveness of PHCNP care (Chambers and West 1978; Spitzer et al. 1973,
1974), implementation efforts ground to a halt in the mid-1980s for a variety
of reasons. These included a lack of remuneration mechanisms for PHCNPs,
reduced physician income, lack of nurse practitioner (NP) role legislation for an
extended scope of practice, inadequate support from policy makers and other
health providers, and a perceived oversupply of physicians, particularly in urban
areas (Kaasalainen et al. 2010; Spitzer 1984). Consequently, PHCNPs disappeared
in all but remote areas and a few sites in southern Canada.
In the mid-1990s to the early 2000s, numerous federal and provincial government
reports, all calling for major primary healthcare reform, identified that the use of
nurses and other healthcare professionals could improve patient access to health
services (Kirby 2002; Mhatre and Deber 1992; Romanow 2002; Stoddart and
Barer 1992). Reform efforts were fuelled by unprecedented federal and provincial
investments in primary healthcare infrastructure and interdisciplinary healthcare
teams, leading to a countrywide emphasis on enhancing health promotion and
improving equitable healthcare access and quality (Hutchison 2008). This context
prompted the revival of governments interest in the PHCNP role and initiated
the second wave of PHCNP role implementation, supported by legislation, regula-
tion, remuneration mechanisms and funded education programs. Foundational
to implementing this role is the abundant research that has shown PHCNPs are
effective, safe practitioners who positively influence patient, provider and health
system outcomes (Dierick-van Daele et al. 2010; Horrocks et al. 2002).
In this paper we examine the current status of the PHCNP role in Canada,
including supply, deployment and practice settings; education; and regulation and
scope of practice. We summarize key issues and challenges to the integration and
long-term viability of the PHCNP role and offer recommendations to address the
challenges. While PHCNPs are also known as family or all-ages NPs, we will use
PHCNPs for the purposes of this paper.
Methods
This paper was developed using the results of the scoping review of the literature
and key informant interviews conducted for a decision support synthesis commis-
sioned by the Canadian Health Services Research Foundation (CHSRF) and the
Office of Nursing Policy in Health Canada (DiCenso et al. 2010b). The litera-
ture review and interviews were carried out to develop a better understanding of
advanced practice nursing roles (NP and clinical nurse specialist [CNS]), their
current use, and the individual, organizational and health system factors that influ-
ence their effective development and integration in the Canadian healthcare system.
The synthesis methods are described in detail in an earlier paper in this issue
(DiCenso et al. 2010c). Briefly, we conducted a comprehensive appraisal of
published and grey literature ever written about Canadian advanced practice
nursing roles as well as reviews of the international literature from 2003 to 2008.
The overall search yielded a total 2,397 papers, of which 468 were included in the
scoping review. Data were extracted from each paper and themes were developed.
The PHCNP-related papers contributed 47% of the Canadian papers included in
the synthesis. A total of 69 papers were primary studies, 19 were reviews and the
remaining articles were essays or editorials.
Interviews (n = 62) and focus groups (n = 4 with a total of 19 participants) were
conducted in English or French with national and international key informants
including NPs, CNSs, physicians, healthcare team members, educators, health-
care administrators, nursing regulators and government policy makers. We used
purposeful sampling to identify participants with a wide range of perspectives on
advanced practice nursing issues in Canada and internationally. All key inform-
ants were asked the same questions, some of which related to the PHCNP role.
The interview questions are described in detail elsewhere (DiCenso et al. 2010c);
briefly, they focused on reasons for introducing the advanced practice nursing
role(s) in interviewees organizations, regions or provinces; how the role(s) were
implemented; key factors facilitating and hampering their full integration at the
individual, organizational and system-level; the nature of their collaborative rela-
tionships; their impact; success stories; and interviewees recommendations for
fully integrating the role. Nearly all of the key informants discussed the PHCNP
role. We developed an initial coding structure of emergent themes from the inter-
views and integrated this structure into a broader, theoretically informed frame-
work that included factors influencing advanced practice nursing role
integration (Bryant-Lukosius and DiCenso 2004; Bryant-Lukosius et al. 2004).
When our synthesis was completed, CHSRF convened a multidisciplinary round-
table to develop recommendations for policy, practice and research.
We synthesized the literature and interview/focus group data by examining the
similarities and differences in themes and common patterns and trends. For this
paper, we focus on findings specific to the PHCNP role in Canada and refer to the
roundtable recommendations where relevant.
Results
We begin our presentation of the findings with a review of the current status of
the PHCNP role in Canada, describing supply, deployment and practice settings;
education; regulation and scope of practice; and liability. Subsequently, we
describe the issues and challenges that most frequently and consistently emerged
from our various data sources: restrictive legislation and regulation, inconsisten-
cies in educational preparation, and the working relationships between PHCNPs
and family physicians.
Current Status of the PHCNP Role in Canada
The potential of PHCNPs to enhance the accessibility and quality of primary
healthcare services has sparked nationwide interest. Perhaps because of this, the
PHCNP role is the fastest-growing advanced practice nursing role in Canada
(Canadian Institute for Health Information [CIHI] 2010). This growth has been
supported by professional, regulatory and government nursing leaders (Carter
et al. 2010) and by the establishment of provincial/territorial NP associations,
some of which are connected with the Canadian Association of Advanced Practice
Nurses (CAAPN).
During the latter part of the 1990s and throughout the 2000s, provinces and
territories each developed their own legislation and regulation for the PHCNP
role (CIHI 2010). Although there was some inter-jurisdictional consultation, the
timing and pace of development depended on factors internal to each province
and territory. The result was a mlange of legislation and regulation. Titles, title
protection and scope of practice were common points of difference. Realizing
that an integrated approach was needed for sustainability of the role within the
country, nursing leaders proposed development of a pan-Canadian framework.
Subsequently, the Canadian Nurse Practitioner Initiative (CNPI) was funded by
Health Canada and sponsored by the Canadian Nurses Association (CNA) (CNA
2008). Under the leadership of the CNPI, extensive literature reviews and discus-
sion papers were prepared on practice, education, legislation, human resource
planning and social marketing, all in relation to the NP role in the Canadian
healthcare system. Specific accomplishments included development and revision
of the Canadian Nurse Practitioner Core Competency Framework (CNA 2005,
2010), a framework that identified the competencies common to all NPs irrespec-
tive of specialization; the Canadian Nurse Practitioner Examination (CNPE)
(CNPI 2006b), developed for PHCNPs only; the Implementation and Evaluation
Toolkit for Nurse Practitioners in Canada (CNPI 2006a); and frameworks for
practice, education, legislation and regulation (CNPI 2006c).
The purpose of the CNPIs legislative and regulatory framework (2006c) was to
protect public interests, facilitate healthcare access, ensure nationwide consistency,
support workforce mobility and position NPs to enable their maximum contribu-
tion to the Canadian healthcare system. The following generic definition of NPs
was developed and recommended for use in Canada:
Nurse practitioners are registered nurses with additional educational
preparation and experience who possess and demonstrate the compe-
tencies to autonomously diagnose, order and interpret diagnostic tests,
prescribe pharmaceuticals and perform specific procedures within their
legislated scope of practice (CNA 2008: 16, 2009).
Although there is no national definition for a PHCNP, it is generally accepted
that PHCNPs provide services to individuals and families across the lifespan and
work in a variety of community-based settings (DiCenso et al. 2003, 2007). The
focus of their practice is health promotion, preventive care, diagnosis and treat-
ment of acute common illnesses and injuries, and monitoring and management
of stable chronic conditions (Caty et al. 2000; DiCenso et al. 2003; Goss Gilroy
Inc. Management Consultants 2001; Sidani et al. 2000; Way et al. 2001). Using
an evidence-informed holistic approach that emphasizes health promotion and
partnership development, NPs complement rather than replace other health-
care providers. Interview participants concurred, explaining that PHCNPs were
introduced to improve accessibility to a range of primary healthcare services and
enhance the quality of chronic disease management. A government interview
participant summarized this perspective as follows:
I think that in the guidelines produced by the [provincial] Nurses
Association, it [PHCNP role] is very well defined; its the intake of vulner-
able clients that say they are dealing with a chronic disease. I think that
forms an integral part because as time goes on this clientele is going
to increase, so we think about diabetes, heart failure, chronic obstructive
lung disease, kidney failure, heart failure all the chronic diseases that
worsen and will increase in number. Monitoring pregnancies, also the
intake of routine health problems, that is essential, and the monitoring
they [PHCNPs] can conduct with people from birth to adulthood, people
who are ambulatory, in terms of [disease] prevention, [health] promo-
tion, to ensure that they help people adopt suitable healthy behaviours to
care for themselves. I would say that it [PHCNP role] centres primarily
around these roles.
Supply, Deployment and Practice settings
Since 2005, CIHI has reported the numbers of NPs in Canada along with demo-
graphic data. These reports are based on annual registration data from provincial
and territorial nursing regulatory bodies. The most recent statistics, reflecting
2008 registration data, indicate that the number of licensed NPs in Canada more
than doubled between 2004 and 2008, increasing from 800 to 1,626 (CIHI 2010).
In 2008, 95% of NPs were female; approximately 76% worked in urban areas
while 24% worked in rural and remote areas; and over 50% of NPs were located
in Ontario. The majority of NPs worked full-time (76%), and 94% reported their
main responsibility was direct patient care. Although these data do not distin-
guish between types of NPs, in 2008 it is reasonable to assume that the majority of
licensed NPs in Canada were PHCNPs. This is because in Ontario, where the larg-
est number of NPs are registered, acute care NPs (ACNPs) did not begin writing
registration examinations until 2008 (Nurse Practitioners Association of Ontario
2009), and therefore very few would be counted as licensed in the 2008 regulatory
data provided to CIHI. In addition, some provinces, for example, New Brunswick,
license only the PHCNP role.
In 2008, approximately 40% of PHCNPs worked in the community sector, 32%
in the hospital sector and 2.4% in the nursing home or long-term care sector;
the remainder worked in other places or did not state their place of employ-
ment (CIHI 2010). Another survey of 371 Ontario PHCNPs in 20042005 found
that the majority of respondents reported working with marginalized popula-
tions (low-income earners, unemployed persons, substance abusers, people with
mental illness, cultural minorities, recent immigrants and HIV/AIDS patients),
and over half (57%) worked in underserviced locations (van Soeren et al. 2009).
There is evidence that PHCNP deployment is expanding to settings that have not
previously employed PHCNPs, such as emergency departments, long-term care
settings and cancer care centres (DiCenso et al. 2007; Donald et al. 2009; Ordre
des infirmires et infirmiers du Qubec 2009; Stolee et al. 2006).
Practice and expectations for the role, as well as the longevity of the role in the
setting and amount of experience in the role, influence PHCNP practice patterns
(Caty et al. 2000; DiCenso et al. 2003; Goss Gilroy Inc. Management Consultants
2001; Sidani et al. 2000; Way et al. 2001). DiCenso et al. (2003) identified three
major focuses for PHCNP practice: condition based, population based or scope
based. In each of these practice models, the PHCNP worked autonomously and
consulted or collaborated with the physician as needed. With a condition-based
focus, the PHCNP practice was primarily based on a specific patient condition
(e.g., congestive heart failure, diabetes, mental health issues or for chronic disease
management). With a population-based focus, the PHCNP practice was primarily
based on a specific type of patient population or geographic area (e.g., teenagers,
children, marginalized people or First Nations people). With a scope-based focus,
the PHCNP primarily saw a broad-based primary care patient population and
consulted or collaborated with the physician mainly with respect to issues beyond
the PHCNPs scope.
Data from interview participants concurred with the literature. The following
quotes from PHCNP interview participants show how their day-to-day practice
activities vary in different settings:
So I see patients from birth to death, for a variety of problems complex
to simple problems. So theres nothing that I really am not able to see,
and generally if theres something thats out of my scope, Ill do what any
family doctor would do, either consult or refer to a specialist.
I go to the school every Monday morning, and Im a resource person and
have some teen clients that find it easier to come and see me there. I
probably spend half to three-quarters of a day and probably eight hours
a week seeing diabetic clients, and I do a monthly presentation at the
library.... The bulk of my time is direct patient care, but I have imple-
mented a number of different educational programs and outreach, and I
collaborate with mental health and public health and the different nurses
and practitioners in other areas with some of the projects they have.
So in some ways our role [in northern remote communities] is broader
than that of a family NP in that we see anybody who comes in through the
door. So we provide public health services, maternal-child, well-women,
prenatal care and, in addition, we see what would normally be seen in a
walk-in clinic, so acute, episodic illness. We also provide emergency care,
which can extend from minor emergencies to life-threatening emergen-
cies. We work Monday to Friday in the clinic, and then we provide on-call
services after hours. This is the model across northern Canada and in
most First Nations and Inuit communities.
The estimated average length of time Canadian PHCNPs spend per patient visit
is 30 minutes (CNPI 2006c). This is consistent with an Ontario study that found
PHCNPs in primary care settings provided services for an average of 14 patients per
day; in long-term and acute care the daily number was 26 (van Soeren et al. 2009).
Education
Since the 1970s, there has been countrywide consensus that additional specific
education beyond a baccalaureate or diploma program is needed to prepare for
PHCNP role requirements. During the second wave of NP implementation,
PHCNP education programs were initiated in most provinces and territories,
beginning in the mid-1990s with the Council of Ontario University Programs in
Nursing (COUPN) post-baccalaureate PHCNP Certificate Program (Cragg et al.
2003; Kaasalainen et al. 2010). Other provinces and territories followed suit, with
some developing programs at the post-diploma or post-baccalaureate level and
others at the masters level (CNPI 2006c). As of 2008, a masters degree from an
approved graduate level PHCNP program became the recommended educational
standard in Canada and internationally (CNA 2008; International Council of
Nurses 2008). That said, only about a third (36.7%) of Canadian NPs meet this
standard (CIHI 2010), and two provinces continue to offer PHCNP education at
the baccalaureate or post-baccalaureate level (Newfoundland and Labrador, and
Saskatchewan). While Ontario prepared PHCNPs at the post-baccalaureate level
for 12 years, the PHCNP education program now provides graduate levels courses
at all nine universities that offer the program. The inconsistency in the education
of PHCNPs is a key issue challenging PHCNP role integration and is discussed
later in this paper and in another paper in this special issue (Martin-Misener et al.
2010).
Regulation and Scope of Practice
All 10 provinces and three territories in Canada now have legislation authorizing
PHCNPs to implement their advanced nursing role (CIHI 2010; Government of
Yukon 2009). Many, but not all, provinces and territories protect the title nurse
practitioner and licensing nomenclature (e.g., RNNP), and processes vary.
Although most jurisdictions require entry-level PHCNPs to complete an exami-
nation to qualify for licensure and/or registration, they differ with respect to the
nature of the examination; some use the national CNPE, which is written, while
others use examinations approved by their province. For example, the Quebec
PHCNP certification exam consists of three parts: a written short answer exam,
a structured oral interview and an objective structured clinical exam (Personal
Communication with Judith Leprohon, Scientific Director, Ordre des infirmires
et infirmiers du Qubec, March 22, 2010), whereas British Columbia uses the
American Nurses Credentialing Center exam (not marked on questions relat-
ing to the American healthcare system) and an objective structured clinical exam
(College of Registered Nurses of British Columbia 2009).
In most jurisdictions, PHCNPs are authorized to make and communicate a diag-
nosis of disease, order and interpret diagnostic and screening tests, and prescribe
medication (CIHI and CNA 2006). However, some jurisdictions apply restric-
tions on which diseases NPs may diagnose (Prendergast 2009), and in Quebec,
establishing a primary diagnosis remains the exclusive domain of physicians
(Gouvernement du Qubec 2005).
Other inter-jurisdictional variations in the scope of PHCNP practice include
differences in prescribing privileges and the ability to refer to a specialist. Some
provinces have prescribing legislation and regulation that restrict PHCNPs to
prescribing from a specified list of drugs (Marchildon 2005), whereas other prov-
inces use an approach based on individual knowledge, education and competence.
Schreiber et al. (2005: 9) describe such a professional practice model as one in
which each provider has sole authority for his or her own practice, responsibility
for decision-making and maintenance of competencies, and assessment of limita-
tions and areas for professional development. Recently some jurisdictions, for
example Nova Scotia and Newfoundland and Labrador, have changed to a broader
approach because the list method is cumbersome and cannot keep pace with
changes in evidenceinformed practice. In December 2009, Ontario passed Bill
179, which will do away with the use of lists for prescribing and ordering diagnos-
tic and laboratory tests (Ministry of Health and Long-Term Care 2009).
Liability
PHCNPs are expected to carry adequate liability coverage. Many receive this
through the Canadian Nurses Protective Society (CNPS) provided through
CNA membership; the CNPS provides $5 million of occurrence-based coverage
for NPs (http://www.cnps.ca). The autonomous nature of PHCNP practice has
created physician concerns related to liability, as physicians have expressed confu-
sion regarding their medicolegal responsibility when in practice with an NP, the
adequacy of NP liability insurance coverage and vicarious liability (for example,
DiCenso et al. 2003; Jones and Way 2004; Martin-Misener et al. 2004; Turris et al.
2005). Two joint policy statements by the CNA, the Canadian Medical Association
and the Canadian Pharmacists Association (CNA 2003) and by the Canadian
Medical Protective Association (CMPA) and the CNPS (2005) provided principles
and criteria for defining scopes of practice and clarified liability issues. A govern-
ment interview participant commented that the joint statement from the CMPA
and CNPS has alleviated concerns around liability. However, issues remain, since
not all PHCNPs are required to choose CNPS coverage and other malpractice
insurance plans may not be as comprehensive. Bill 179 in Ontario requires all
regulated healthcare providers to carry liability coverage (Ministry of Health and
Long-Term Care 2009).
Key Issues and Challenges to PHCNP Role Integration
Synthesis of the literature and the participant interview and focus group data
revealed that the most frequently and consistently identified challenges limiting
the full integration of the PHCNP role into the Canadian healthcare system are
(1) restrictive legislation and regulation, (2) inconsistencies in the educational
preparation of PHCNPs across Canada and (3) working relationships between
PHCNPs and family physicians.
Restrictive Legislation and Regulation
Although there have been some successes, legislation and regulation issues
continue to create barriers to PHCNP practice, restricting role integration and
compromising efficiencies. Many papers in our scoping review reported legis-
lative and regulatory restrictions on PHCNP scope of practice (e.g., Advisory
Committee on Health Human Resources et al. 2001; de Witt and Ploeg 2005;
DiCenso et al. 2007; Fahey-Walsh 2004; Goss Gilroy Inc. Management Consultants
2001; Gould et al. 2007; Humbert et al. 2007; Nova Scotia Department of Health
2004; Nurse Practitioners Association of Ontario 2007). One of these barriers
is legislation that restricts PHCNP prescribing. At the provincial/territorial level
the issue is the use of drug lists and formularies, while at the federal level it is the
prescribing of narcotics and controlled substances.
Interview participants in our synthesis repeatedly indicated the list approach to
prescribing was problematic. Lists became rapidly out of date, were restrictive to
practice and added costs and inefficiencies to health service delivery because NPs
had to wait for a physician to sign a prescription or to order a test. The follow-
ing quotes from two interview participants an administrator and a regulator
reflect this dissatisfaction:
[Lists are] a real barrier to practice. So you hire an NP and the NP needs
to work around if there are certain drugs that come on the market it
would actually be better for her to prescribe but she cant prescribe them.
Shes got to go to a physician to prescribe this particular drug. So those
are the kinds of things that add to the barriers from a systems perspective,
and they add to the inability to hire. I think it adds to the barriers that
nurse practitioners come up against. Theres a lack of knowledge of what
their [NP] full scope of practice can and should be.
We just have to get rid of lists because we have lists of medications and we
have lists of tests that an [NP] can order. Of course, healthcare changes all
the time. I think rather than having all those lists that are very constrain-
ing and out of date pretty much the day that theyre passed, we really need
to move beyond that into more broad categories and allowing nurses to
use their own knowledge, skill and judgment to decide when and what
they can order within those categories, which might be constrained but I
think the legislation as it stands right now doesnt work. I actually think
that theres starting to be some realization at the level of the government
that it doesnt work.
Another example of a jurisdictional difference in scope of practice resulting from
legislative and regulatory policy was the ability of PHCNPs to refer to medical
specialists. In some jurisdictions, higher rates of remuneration are paid to medical
specialists for patient referrals made by a physician, thereby preventing PHCNPs
from making referrals to specialists (DiCenso et al. 2003; Gould et al. 2007).
Interview participants commented further that other legislative barriers restricted
NP practice and interrupted continuity of patient care. The following quotes from
healthcare administrator participants in two provinces illustrate this:
One of the other biggest barriers is the Public Hospitals Act in Ontario.
So for example, the Public Hospitals Act doesnt allow an NP to admit or
discharge. They [NPs] can care for the person [using medical directives]
while theyre in the hospital, but they cant admit them and they cant
discharge them. And if they truly are a PHCNP, and particularly in the
rural and remote areas, you have to have a physician to admit a person but
that physician doesnt know that person at all. The NP knows the person.
And the argument the physician would make on that is that thats not
primary healthcare then. But its about being client centered. And I think
thats the piece and the Public Hospitals Act has a whole bunch of other
barriers in it. Its archaic is what it is.
Although we have a very broad scope of practice in BC, there are a couple
of regulations that do create some barriers. So theres some regulations
related to some of the different forms that they [NPs] can be responsible
for. Im thinking of things like motor vehicle forms and WCB [Workers
Compensation Board] forms. The NPs arent able to complete those
independently, and they have to have a physician co-signing those. That
created a barrier because basically theyve [NP] done all the work with
the patient but then they have to just involve a physician simply because
of the regulation. I know those have been put forward, and theres work
underway to have them resolved.
Other examples of barriers included legislation that governs other disciplines and
multiple health system activities (CNPI 2006c). For example, when PHCNPs were
introduced in Nova Scotia, changes had to be made to the Pharmacy Act so that phar-
macists could fill prescriptions written by PHCNPs (Martin-Misener et al. 2004).
Our scoping review identified a need for a pan-Canadian approach to legislative
and regulatory framework development and implementation to ensure consist-
ency for PHCNPs (CNPI 2006b, 2006c; Thille and Rowan 2008). This recommen-
dation was supported by the multidisciplinary roundtable convened by CHSRF
to formulate evidence-informed policy and practice recommendations based on
the synthesis findings (DiCenso et al. 2010c). The CHSRF roundtable specifi-
cally recommended that a pan-Canadian approach to regulatory standards and
requirements would facilitate provider mobility in response to population health-
care needs and improve recruitment and retention to advanced practice nursing
roles (DiCenso et al. 2010c).
Inconsistencies in the Educational Preparation of PHCNPs across Canada
Although the CNA (2008), CNPI (2006b) and International Council of Nurses
(2008) have specified that graduate degree preparation is required for all advanced
practice nursing roles, uptake of this standard for PHCNP education is variable
across Canada (Martin-Misener et al. 2010). The need for graduate education for
ACNPs and CNSs, both of which typically provide services in organizations with
many resources and supports, unlike the PHCNP role, has not been questioned.
Only the PHCNP role has been at the centre of the debate over education require-
ments in Canada (CNPI 2006c; Schreiber et al. 2005). Even if nursing registra-
tion and education organizations in provinces and territories decide they want
graduate education to be the standard of PHCNP education, their governments
may decide the proposed change to the educational requirements for PHCNPs
should first be reviewed by the Health Canada and Federal, Provincial, Territorial
Advisory Committee on Health Delivery and Human Resources (Dault et al. 2004;
Health Canada, and Federal, Provincial, Territorial Advisory Committee on Health
Delivery and Human Resources 2006).
The controversy about PHCNP education requirements was reflected in comments
from our interview participants. Most participants strongly supported graduate
education for all advanced practice nursing roles and told us that until recently
the inconsistent educational requirements across provinces had created barriers to
the internal mobility of PHCNPs without graduate degrees. One participant used
the term ghettoized to describe what was happening to PHCNPs educated with
a post-baccalaureate or post-diploma certificate, as these PHCNPs could not prac-
tise in a province that required graduate education for PHCNPs. This may change
now that the Agreement on Internal Trade (AIT) prohibits refusal of a license to a
PHCNP, or other professional, previously licensed in another province or territory
on the basis of their education qualification (Forum of Labour Market Ministers
and Labour Mobility Coordinating Group 2009). Requests for exceptions to the
requirements of the Act must justify why a particular measure is needed to meet
a legitimate objective. It remains to be seen what impact the AIT will have on
PHCNP mobility and whether provincial nursing organizations will try to defend
the need for graduate education for the PHCNP role.
Nursing regulator participants indicated that the requirement for graduate
education in British Columbia and Quebec was heavily influenced by physicians,
who insisted graduate education should be the basis for the advanced knowledge
and skills required of the PHCNP role. Physician endorsement of the need for
graduate education was regarded as a key facilitator in these provinces. However,
a small number of government participants in our synthesis expressed worries
about the time lag associated with higher educational standards, the absence of
evidence to justify the need for a masters degree, the tuition costs associated
with a higher level of training, the impact on the number of NPs in the system
and the possibility that NPs would then request higher salaries without increas-
ing patient volume and access.
The Working Relationships between PHCNPs and Family Physicians
Several papers identified the importance of the working relationship between
PHCNPs and family physicians (e.g., Way et al. 2000). Simply stated, if their rela-
tionship was good, it was a key facilitator of PHCNP role implementation and
integration, but if not good, it became a significant barrier (DiCenso et al. 2003;
Nova Scotia Department of Health 2004).
Physician interview participants indicated that positive, respectful and trusting NP
physician relationships, along with good communication, willingness to deal with
conflict, organizational structure and matching of personalities, all contributed to
NP role integration. One physician we interviewed commented that if everybody
feels theyre getting more out of it than theyre losing, then its going to be success-
ful, adding that by working together, NPs and physicians could see more patients,
provide better services and ensure patients did not fall through the cracks.
Nevertheless a large number of papers described physician resistance to the
PHCNP role (e.g., Cusson 2004; DAmour et al. 2009; DiCenso et al. 2003; Hass
2006; Ontario Medical Association and Registered Nurses Association of Ontario
2003; Pong and Russell 2003; Sloan et al. 2006). The principal reasons for this
resistance related to liability concerns (e.g., Bailey et al. 2006; Martin-Misener et
al. 2004; Way et al. 2001), scope of practice issues (Beaulieu et al. 2009; DiCenso
et al. 2003), lack of role clarity (Beaulieu et al. 2009; DAmour et al. 2009) and
concern about NP independent practice (Gosselin 2001; Lagu 2008). Several
reasons for the inter-professional tension between PHCNPs and family physicians
were suggested, with some authors attributing it to system factors, such as how
the Medicare system structure and funding had established physicians as the gate-
keeper to the healthcare system (van der Horst 1992).
Another important reason cited for physician resistance related to the vari-
ous funding arrangements for physician services. Funding arrangements that
created financial competition and an employeremployee relationship between
a physician and PHCNP were reported to obstruct collaboration (Jones and Way
2004; Nurse Practitioners Association of Ontario 2008). The need for adequate
compensation models for physicians was stressed by healthcare administrator
and physician interview participants. Not being able to bill for collaborating with
PHCNPs was reported to be a disincentive for physicians to work with them.
The literature (Advisory Committee on Health Human Resources et al. 2001;
deWitt and Ploeg 2005; DiCenso et al. 2003; Jones and Way 2004; Schreiber et
al. 2005) and many interview participants indicated fee-for-service reimburse-
ment impeded PHCNP integration when healthcare activities shifted to NPs and
resulted in loss of physician income. One participant explained,
If the physician thinks, if I dont see that person I dont get paid, its a huge
barrier because they dont want somebody else to see that person. Or they
want that person [NP] to see them but then they need to see them just so
they can get paid. Thats a problem to the whole health system.
Participants also highlighted that physicians paid through fee-for-service essen-
tially run their practice as a small business. As such, they have expenses and obliga-
tions that other healthcare professionals may not be aware of, as well as a sense of
ownership based on their investment in the practice. As one physician explained,
It is often forgotten that the physicians, in our case, own the practice.
Weve invested in it, we have debts and we bought all the equipment and
somehow that doesnt seem to be [recognized]. it is still our business.
Several interview participants commented on how financial incentives for physi-
cians interfered with PHCNP role integration. For example, incentives offered
to physicians to hire PHCNPs position the PHCNPs as employees rather than
colleagues. The unintended consequences of incentives to physicians for meet-
ing preventive care target numbers were also problematic, because the work of
PHCNPs was included in target achievement, yet sharing the incentive was at the
discretion of the physician. Voicing their disapproval, the Nurse Practitioners
Association of Ontario stated that in the spirit of team development, the notion
that one provider is being paid an incentive for the work of others is incompatible
and inconsistent with the interprofessional approach to care (2008: 2); instead,
they advocated for team-related bonuses. Some primary care practices have
converted these physician-specific incentives into team-based incentives in recog-
nition of team members contributions to preventive care services. A government
interview participant commented that remuneration mechanisms need refine-
ment to ensure fair compensation of primary healthcare teams and suggested a
team-based approach to remuneration negotiations.
A new practice model for PHCNPs in Ontario is the NP-led clinic, which has had
unplanned consequences for relationships between PHCNPs and family physi-
cians. This model was developed to facilitate PHCNPs working collaboratively
with physicians to provide healthcare to patients who previously did not have a
primary healthcare provider (DiCenso et al. 2010a). However, the NP-led clin-
ics encountered strong opposition from the Ontario Medical Association, which
alleges that these clinics promote an independent practice model that conflicts
with the principles and philosophy of collaborative practice (Ontario Medical
Association 2008; DiCenso et al. 2010a); yet these PHCNPs have established
strong collaborative relations with the consulting physicians and other healthcare
providers who work in these clinics.
There is a recognized overlap in the scope of practice of PHCNPs and family
physicians (Marchildon 2005), illustrated clearly by this PHCNP interview
participant, who said, my role really entails a lot of what a family doctor would
do. Depending on how well this overlap is understood and managed, it can be a
source of tension (Jones and Way 2004; Way et al. 2000). Many interview partici-
pants acknowledged the overlap in practice between a PHCNP and family physi-
cian, identifying that strong collaborative relationships were needed to negotiate
shared areas of practice. One family physician commented,
I think the first step is you sit down and start from square one and say,
who are we and what do we really need in this particular setting in terms
of a skill set. What is it that you feel comfortable doing? What is it that Im
doing? How can we complement each other? Working through it, sort of
compromising.
Another family physician offered further thoughts about the specific approaches
PHCNPs and family physicians can use to establish and enhance their collaboration:
So you do it in a very conscientious and concerned fashion to ensure that
at the end of the day were meeting the needs of our patients. We have to
make sure that the providers, in this case the NPs and family docs, have
worked through how we are going to do this and how do we make sure
that we support each other in doing it. So its a balance between (1) iden-
tifying how we can do this, (2) setting up the structures [and] (3) making
sure that the other people in the clinic, particularly reception staff, under-
stand their [PHCNP] roles and how to refer to them, because often we
leave them [reception and other staff] out and they have no clue. So
that the whole team understands how these roles, how this new team, new
way of doing business, is going to unfold, you have to factor in meetings
to be able to debrief and figure it out, and youve got to be able to, when
its not working, talk about it. You have to look at the professional devel-
opment thats needed for individuals both in terms of their clinical skills
as well as potentially just to understand how you work as a team.
Many of these suggestions were also found in the literature. For example, some
authors advocated for a structured approach to developing collaboration that
emphasizes the importance of respect, communication and trust (Jones and
Way 2004; Way et al. 2000, 2001). Others reported specific strategies to improve
communication and collaboration, such as collaborative practice agreements that
plainly define mutual responsibilities (Martin-Misener et al. 2004; Sebas 1994),
clearly established prompt communication mechanisms (Donald et al. 2009) and
processes to recognize and openly explore turf protection in the context of the
publics need for accessible quality healthcare (Caprio 2006; Donald et al. 2009).
Discussion
The purpose of this paper was to provide an overview of the current status
of the PHCNP role in Canada and the challenges impeding full integration
of the role into the Canadian healthcare system based on the findings from
our decision support synthesis. The numbers of PHCNPs are increasing in
Canada, they are practising in a wide range of practice settings and PHCNPs
are supported with legislation and regulation in every province and terri-
tory. It remains to be seen whether this trend will continue nationally and
whether the increase in the uptake of the PHCNP role will be evident in
all provinces and territories. Ongoing studies are needed to monitor these
trends. While several provinces are gathering annual data about PHCNPs
in their own jurisdictions, a national tracking method is needed to better
understand and compare nationwide practice pattern trends and barriers
to practice. A national tracking system could facilitate comparisons and
contrasts of PHCNP practice in different contexts and settings, thereby
informing policy, scope of practice and legislative decisions.
While much has been accomplished to advance the implementation and inte-
gration of PHCNPs in Canada, a number of hurdles and obstacles block the
path to full integration and sustainability of the role. Our synthesis findings
and the recommendations from the CHSRF roundtable point to the need for
clear, consistent legislation and education standards across all provinces and
territories to support PHCNP role clarity, credibility and portability.
The restrictions on PHCNPs legislated scope of practice interfere with
the ultimate goal of providing safe, effective and timely care for patients.
Limiting the ability of PHCNPs to prescribe and adjust patients medications
based on the most recent evidence and the inability to refer patients directly
to a specialist result in additional system costs and delays for patients,
because they must first see a family physician. Moreover, the drugs and diag-
nostic tests that a PHCNP orders in a community health centre, a traditional
setting in which PHCNPs practice and for which drug lists usually have
been designed, may be quite different from the typical tests and medications
required in a nursing home, emergency department or palliative care setting,
some of the newer settings in which PHCNPs are practising. In addition to
prescribing policies, each province and territory will need to review the vari-
ous legal acts and regulations that form the basis of health and social policy
to identify and remove barriers to NP practice in order to improve the qual-
ity and efficiency of primary healthcare. The same process needs to occur
at the federal level. The extent of the legislation and policy changes needed
is astonishing; see for example, the legislated restrictions on NP practice
identified in the frequently asked questions in the newly released NP toolkit
developed by the College of Registered Nurses of Nova Scotia (2010).
A number of Canadian jurisdictions have a health professions act that
provides a regulatory structure to govern registered nurses, physicians, NPs
and other regulated healthcare professionals (College of Registered Nurses of
British Columbia 2010). Provincial and territorial acts, policy and dialogue
among and between professions typically help to determine the specific
bylaws and regulations that determine scope of practice in each province
and territory. The emphasis on primary healthcare has enhanced the shared
scope of practice between PHCNPs and family physicians. These shared
areas of practice are highly valued because they facilitate timely patient
access to primary healthcare services. However, tensions between PHCNPs
and physicians can arise when there are misunderstandings of the differences
between autonomous and independent practice and when funding require-
ments impede collaboration and delay the provision of healthcare services.
The context of contemporary healthcare reform is requiring many healthcare
professions to adjust to changes in the activities they and others carry out,
creating fears related to loss of autonomy and control and leading to resist-
ance. Healthcare team collaboration depends on respect, trust, and mutual
understanding of and willingness to negotiate and re-negotiate professional
roles. It depends on a non-hierarchical dynamic and a conviction that every
healthcare team member is getting more out of it than they are losing.
The variability in educational preparation may place PHCNPs with gradu-
ate degrees at an advantage when applying for jobs, compared with their
post-baccalaureate-prepared colleagues. A graduate degree typically prepares
PHCNPs to practise at an advanced level (i.e., critiquing research and its
application to patient care, purposely selecting and applying theories based
on patient needs, leading community development and healthcare interven-
tion programs, and evaluating and understanding policy and ways to influ-
ence it). The roundtable recommended that in order to facilitate provider
mobility in response to population healthcare needs and improve recruit-
ment and retention to advanced practice nursing roles, a pan-Canadian
approach should be taken, in collaboration with educators, to standardize
advanced practice nursing educational standards, requirements and proc-
esses (DiCenso et al. 2010c). The inclusion of policy makers in these discus-
sions is critical in order for educators and policy makers to understand
and appreciate their mutual concerns regarding health human resources
and quality of healthcare. Following agreement on educational standards,
an accreditation or another type of review process for PHCNP education
programs is important to ensure that educational institutions adhere to the
national standards.
The interest in the PHCNP role is closely tied to the reawakened nation-
wide awareness of the importance of primary healthcare in renewing and
sustaining the publicly funded healthcare system that Canadians clearly
value (Romanow 2002). Increasingly, evidence and value for money are
becoming key considerations in decision making about the initiation and
continuation of innovations (Health Council of Canada 2009). The need for
further research to better understand the benefits of the care provided by
PHCNPs was underscored by the CHSRF roundtable (DiCenso et al. 2010c).
Some of this evidence is beginning to accumulate in Canada. Russell et al.
(2009) found that the inclusion of PHCNPs in primary healthcare models in
Ontario was associated with improved chronic disease management and that
longer patient consultations benefited those with chronic conditions. Other
studies have shown that healthcare teams that include PHCNPs improve
accessibility to primary healthcare, especially in rural areas (Centre for Rural
and Northern Health Research 2006; Martin-Misener et al. 2009). In addi-
tion, an Ontario study found that the addition of PHCNPs to an emergency
department resulted in a significant reduction in wait times, length of stay
and left-without-treatment rates (Ducharme et al. 2009). A similar study in
Alberta found reduced wait times and improved throughput for low-acuity
patients (Steiner et al. 2009). Patient satisfaction with the role continues to
be high; according to a July 2009 Harris/Decima survey, the Canadian public
is increasingly aware of and comfortable with NPs, and many more citizens
are willing to see an NP instead of their physician than have had the oppor-
tunity to do so (Harris/Decima 2009).
Conclusion
In summary, there is a need for a pan-Canadian approach to the educa-
tion, supply, legislation and regulation of PHCNPs that builds on the foun-
dational work of the CNPI. The overlapping scope of practice between
PHCNPs and family physicians requires open dialogue and recognition of
the historical context of role development to enable both professions to work
collaboratively to provide optimal care to patients in an effective healthcare
system for all Canadians.
Acknowledgements
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114
The Acute Care Nurse Practitioner
Role in Canada
Kelley Kilpatrick, RN, PhD (co-lead author)
Postdoctoral Fellow, CHSRF/CIHR Chair Program in Advanced Practice Nursing (APN)
St-Jrme, QC
Patricia Harbman, NP-PHC, MN/ACNP Certificate, PhD(c), University of Toronto (co-lead
author)
Oakville, ON
Hamilton, ON
Halifax, NS
Hamilton, ON
Toronto, ON
Hamilton, ON
Ivy Bourgeault, PhD
Ottawa, ON
Hamilton, ON
Abstract
The acute care nurse practitioner (ACNP) role was developed in Canada in the late
1980s to offset rapidly increasing physician workloads in acute care settings and to
address the lack of continuity of care for seriously ill patients and increased complex-
ity of care delivery. These challenges provided an opportunity to develop an advanced
practice nursing role to care for critically ill patients with the intent of improving conti-
nuity of care and patient outcomes. For this paper, we drew on the ACNP-related find-
ings of a scoping review of the literature and key informant interviews conducted for
a decision support synthesis on advanced practice nursing. The synthesis revealed
that ACNPs are working in a range of clinical settings. While ACNPs are trained at the
masters level, there is a gap in specialty education for ACNPs. Important barriers to
the full integration of ACNP roles into the Canadian healthcare system include lack of
full utilization of role components, limitations to scope of practice, inconsistent team
acceptance and funding issues. Facilitators to ACNP role implementation include
clear communication about the role, with messages tailored to the specific infor-
mation needs of various stakeholder groups; supportive leadership of healthcare
managers; and stable and predictable funding. The status of ACNP roles continues to
evolve across Canada. Ongoing leadership and continuing research are required to
enhance the integration of these roles into our healthcare system.
Introduction
The integration of nurse practitioner (NP) roles into acute care settings began in
the late 1980s with their introduction into tertiary-level neonatal intensive care
units (NICUs) in Ontario (DiCenso 1998). At that time, the acute care nurse
practitioner (ACNP) role was developed to offset rapidly increasing physician
workloads resulting from a shortage of pediatric residents (Paes et al. 1989) and
to address the lack of continuity of care for seriously ill patients (Pringle 2007)
and the need to deliver increasingly complex care (Hravnak et al. 2009). These
challenges provided an opportunity to develop an advanced practice nursing role
to care for critically ill infants (Hunsberger et al. 1992). The increasing complexity
of healthcare services across medical conditions for all ages (Canadian Institute
for Health Information [CIHI] 2008b; Hogan and Hogan 2002) speaks to an
ongoing need for these roles in the Canadian healthcare system.
The Canadian Nurses Association (CNA) has defined NPs as registered nurses
with additional educational preparation and experience who possess and demon-
strate the competencies to autonomously diagnose, order and interpret diagnostic
tests, prescribe pharmaceuticals, and perform specific procedures within their
legislated scope of practice (CNA 2009b:1). ACNPs, also known as specialty or
specialist NPs, as well as adult, pediatric and neonatal NPs, provide advanced
nursing care for patients who are acutely, critically or chronically ill with complex
conditions. To facilitate comparisons with existing literature, the term ACNP
will be used to describe specialty NPs practising in acute care in hospital or in
specialized outpatient settings.
Numerous randomized controlled trials of ACNPs have been conducted in the
United States (Allen et al. 2002; Ettner et al. 2006; Fanta et al. 2006; Ganz et al.
2000; Gordon 1974; Krichbaum 2007; Pioro et al. 2001; Powers et al. 1984; Rawl
et al. 1998; Shebesta et al. 2006), and in the United Kingdom (Cooper et al. 2002;
Dawes et al. 2007; Harris et al. 2007; Hill et al. 1994; Sakr et al. 1999; Stables et al.
2004), with fewer studies in Australia (Chang et al. 1999) and Canada (Mitchell-
DiCenso et al. 1996a). These studies have consistently demonstrated the effective-
ness and safety of ACNPs in a variety of clinical settings (e.g., emergency depart-
ment, medical inpatient setting, NICU, outpatient clinic), based on a variety of
patient and healthcare system outcomes (e.g., patient health status, quality of
care, patient or provider satisfaction, health system costs and length of stay). The
contribution of the ACNP role is in the delivery of multidimensional (DAmour
et al. 2007) and patient-centred care that includes pharmacological and non-
pharmacological therapies and that enhances patient self-care abilities, improves
symptom management and improves patients abilities to perform regular activi-
ties (Sidani 2008; Sidani et al. 2006a). Staff nurses, physicians, administrators and
ACNPs have reported that the ACNP role improves continuity of care (van Soeren
and Micevski 2001).
The purpose of this paper is to describe the current status of ACNP roles in
Canada. We provide an overview of ACNP education, legislation and regulation,
and supply, deployment and work settings. In addition, we summarize key issues
influencing the full integration of ACNP roles into the Canadian healthcare system.
Methods
This paper was developed using the results of a scoping review of the literature
and key informant interviews conducted for a decision support synthesis commis-
sioned by the Canadian Health Services Research Foundation (CHSRF) and the
Office of Nursing Policy in Health Canada to develop a better understanding of
advanced practice nursing roles, their current use, and the individual, organiza-
tional and health system factors that influence their effective development and
integration in the Canadian healthcare system (DiCenso et al. 2010a).
The synthesis methods are described in detail in an earlier paper in this issue
(DiCenso et al. 2010b). Briefly, we conducted a comprehensive appraisal of
published and grey literature ever written about Canadian advanced practice
nursing roles and reviews of the international literature from 2003 to 2008. The
overall search yielded a total of 2,397 papers, of which 468 were included in
the scoping review. The ACNP-related papers contributed 17% (59/349) of the
Canadian papers included in the synthesis. A total of 20 papers were primary
studies, two were reviews and the remaining articles were essays or editorials.
Forty percent of the Canadian papers related to the ACNP role were from Quebec,
attributable to the fact that this province recently implemented specialty-specific
roles in cardiology, nephrology and neonatology (Ordre des infirmires et infirm-
iers du Qubec [OIIQ] and Collge des mdecins du Qubec [CMQ] 2006a,
2006b, 2006c, 2006d).
Interviews (n = 62) and focus groups (n = 4 with a total of 19 participants) were
conducted in English or French with national and international key inform-
ants, including clinical nurse specialists (CNSs), NPs, physicians, healthcare team
members, educators, healthcare administrators, nursing regulators and govern-
ment policy makers. We used purposeful sampling to identify participants with
a wide range of perspectives on advanced practice nursing issues in Canada and
internationally. All key informants were asked the same questions, some of which
related to the ACNP role. We developed an initial coding structure of emergent
themes from the interviews and integrated this structure into a broader, theoreti-
cally informed framework that included factors influencing advanced practice
nursing role integration (Bryant-Lukosius and DiCenso 2004; Bryant-Lukosius et
al. 2004). When our synthesis was completed, CHSRF convened a multidiscipli-
nary roundtable to develop recommendations for policy, practice and research.
For this paper, we focus on key informant interviews and papers that address the
ACNP role in Canada and refer to roundtable recommendations where relevant.
International literature has been used to provide global context and for further
discussion about key issues when relevant. Data from the different sources are
presented separately and where appropriate are synthesized (OCathain 2009).
Results
We begin our presentation of the findings with a review of key contextual factors
affecting the ACNP role in Canada, followed by the most frequently identified
issues and challenges that emerged from the literature and the interviews.
Current Status of ACNP Roles in Canada
Within the Canadian and international literature, there is agreement on the
components of the ACNP role (Almost and Laschinger 2002; Howie-Esquivel and
Fontaine 2006; Royal College of Nursing 2008; Sidani and Irvine 1999). ACNPs
share the core competencies with other types of advanced practice nursing roles;
these core competencies include direct patient care, research, education, consulta-
tion and leadership activities (Schober and Affara 2006; Schreiber et al. 2005a). An
advanced level of practice integrates graduate-level education, in-depth nursing
knowledge, and expertise in meeting the needs of individuals, families, groups,
populations or communities (CNA 2008). The average amount of time that
ACNPs spend in clinical practice is 70% to 80% (DAmour et al. 2007; Sidani et
al. 2000), although it ranges from 25% to 100% (Hurlock-Chorostecki et al. 2008;
Roschkov et al. 2007; Turris et al. 2005).
Education
McMaster University established the first graduate program to train ACNPs in
neonatology in 1986. The program included problem-based learning and super-
vised clinical practice (Mitchell et al. 1995). Evaluation of the neonatal ACNP grad-
uates found their knowledge levels and problem-solving, clinical and communica-
tion skills to be similar to those of pediatric residents (Mitchell et al. 1991). Further,
using a before-and-after outcome evaluation of the ACNP program, Mitchell et al.
(1995) found that the program met its competency objectives for students.
The ACNP program at the University of Toronto, which began in 1993, was the
first to offer a graduate-level NP program outside neonatology (Simpson 1997).
Educational programs for ACNPs include a combination of graduate education
and clinical experience (CNA 2008). Most provinces offer generic graduate ACNP
programs, for example in an adult-focused specialty (CNA 2008), where the
knowledge and skills specific to the desired clinical specialty are obtained through
learning opportunities such as clinical placements and preceptorships (Rutherford
and Rutherford Consulting Group Inc. 2005). The exceptions to this are neona-
tology, which remains a specialized program in all provinces where it is offered
(Rutherford and Rutherford Consulting Group Inc. 2005), and ACNP training in
Quebec (OIIQ 2009). ACNPs in Quebec are authorized to practise only in the clin-
ical specialty area in which they are trained (Allard and Durand 2006; OIIQ/CMQ
2006d), and specialty training and certification are required for using the title
specialized (Bussires and Parent 2004). DAmour et al. (2009) recommended
a re-evaluation of the training requirements for ACNPs in Quebec because the
course work and clinical requirements were extraordinarily heavy, a result of joint
input into curriculum content by both the medical and nursing licensing boards.
Other jurisdictions, such as Alberta, recognize specific streams according to educa-
tional preparation and a certification exam, including family (all ages), pediatric
or adult (College and Association of Registered Nurses of Alberta [CARNA] 2010).
A more detailed description of the educational requirements of advanced practice
nurses, including ACNPs, can be found in Martin-Misener et al. (2010).
In our synthesis, we found that access to clinical specialty education was limited
in Canada and that this was notable because specialty education has been shown
to be significant in developing role confidence and job satisfaction (Bryant-
Lukosius et al. 2007), as well as in developing self-confidence and the ability to
solve complex problems (Richmond and Becker 2005). Roots and MacDonald
(2008) conducted an exploratory study of NPs and stakeholders to identify the
factors influencing NP role implementation in British Columbia and reported a
mismatch between NP education and available positions. For example, some NPs
educated as primary healthcare NPs were working in acute care or with special-
ized populations. Schreiber et al. (2005a) found that advanced practice nurses in
British Columbia needed to engage in both formal and informal education oppor-
tunities to further role development. ACNP interview participants in our synthesis
suggested that the length of current NP programs is adequate, but increasing the
intensity of the practice component would better prepare them for practice expec-
tations after graduation. They suggested increasing the practice component via a
residency or internship program.
Legislation and Regulation
All 13 provinces and territories in Canada have enacted legislation for the NP
role (Hass 2006; Yukon Registered Nurses Association [YRNA] 2009). Ten of
these jurisdictions have provisions for NPs to practice in acute care sectors
(Association of Registered Nurses of Prince Edward Island 2007; CIHI and
CNA 2006; Health Professions Regulatory Advisory Council [HPRAC] 2007a,
2007b). In New Brunswick, the Northwest Territories and Nunavut, only primary
healthcare/family NPs are eligible for registration (HPRAC 2007a, 2007b). The
Yukon government has recently enacted legislation that allows NPs to practise in
acute, primary and long-term care settings using the NP designation, and work
is currently under way to develop regulations and guidelines in this jurisdiction
(Government of Yukon 2009; YRNA 2009).
ACNPs in most jurisdictions are authorized to perform the following functions: (1)
diagnose a disease, disorder or condition, (2) order and interpret diagnostic and
screening tests and (3) prescribe medications (CIHI and CNA 2006). The level of
autonomy to perform these functions varies across jurisdictions and depends on
the laws regulating practice in each jurisdiction (CIHI and CNA 2006). For exam-
ple, in Quebec, activities such as determining the initial diagnosis of disease and
completing death certificates remain the exclusive domain of physicians (OIIQ and
CMQ 2006d). However, ACNPs in Quebec can identify and manage complications
related to a primary diagnosis made by a physician (Gouvernement du Qubec
2010; OIIQ and CMQ 2006d). Taking another example, in Ontario, the Regulated
Health Professions Act (RHPA), in conjunction with individual professional acts
such as the Nursing Act, regulates which professions have the authority to perform
13 controlled acts. These controlled acts include activities considered potentially
harmful if performed by an unqualified person (Government of Ontario 1991).
Through these mechanisms, NPs have the authority to diagnose, order laboratory
and diagnostic testing, and prescribe treatments (College of Nurses of Ontario
[CNO] 2009a). However, the Public Hospitals Act (Regulation 965) restricts NPs
prescribing authority for medications to outpatients only (CNO 2007). Due to this
regulation, ACNPs in Ontario who provide services to inpatients must continue
to utilize medical directives to carry out the extended controlled acts (CNO 2007).
The government is currently considering these regulations (Ontario Ministry of
Health and Long-Term Care [MoHLTC] 2009b).
Another legislative issue experienced in many jurisdictions, for example Alberta,
British Columbia, Ontario and Quebec, pertains to the lack of patient admis-
sion and discharge privileges for ACNPs (CARNA 2005; CNO 2007; College of
Registered Nurses of British Columbia 2008, 2009; Gouvernement du Qubec
2010). Hurlock-Chorostecki et al. (2008) argue that the lack of admission and
discharge privileges limits the ACNPs ability to provide coordinated and timely
care to patients. On the other hand, the lack of admission and discharge privi-
leges has not been identified as a significant issue for ACNPs in British Columbia
(Roots and MacDonald 2008). Some authors have noted that these types of legis-
lative and regulatory barriers indicate a lack of organizational and system-level
structures to fully develop ACNP roles (DAmour et al. 2007; OIIQ 2009).
Supply, Deployment and Work Settings
Until recently, in some provinces ACNPs have not been licensed and, therefore,
not included in the regulatory data provided to CIHI. Thus the actual number of
ACNPs in Canada is difficult to determine. Nevertheless even with these limita-
tions, according to CIHI the numbers of ACNPs in Canada increased between
2003 and 2007 in all jurisdictions by about 5% overall (CIHI 2008a). In a recent
provincial report (OIIQ 2009), the number of ACNPs in Quebec increased from
16 in 2007 to 41 in 2009.
Approximately 31% of the identified NP workforce in Canada works in the acute
care sector (CIHI 2010). In Canada, ACNPs are found in various clinical settings
including palliative care (Williams and Sidani 2001), oncology (Bryant-Lukosius
et al. 2007), cardiovascular surgery, geriatrics, medicine, pediatrics, nephrology,
trauma (Sidani et al. 2000), cardiology (Roschkov et al. 2007; Thompson and
Dykeman 2007), neonatology (DiCenso 1998; Morneault 2002) and mental health
(CIHI 2008a). The most common specialties reported in a recent Ontario ACNP
workforce study were cardiology, internal medicine, surgery, critical care, pediatrics
and neonatology (Hurlock-Chorostecki et al. 2008). Forty percent of the ACNPs
who participated in this study worked in ambulatory care, and approximately one
quarter of these worked exclusively in that area (Hurlock-Chorostecki et al. 2008).
ACNPs are reported to provide services for an average of 11 patients per day
(Hurlock-Chorostecki et al. 2008). However, this number varies considerably
across specialties, ranging from two to four patients in palliative care (Williams
and Sidani 2001), seven to eight patients in cardiology (Griffiths 2006) and 27
patients in dialysis (Harwood et al. 2004).
Using a descriptive correlational design and a convenience sample of 57 ACNPs
working in a variety of medical and surgical specialties, Irvine et al. (2000) found
that ACNPs perform an average of 24 clinical (patient care) and non-clinical (e.g.,
education, administration and research) activities per day. ACNPs engage most
in direct patient care activities, followed by diagnostic activities, care planning
and coordination (Sidani et al. 2000). In contrast to these patient-focused clinical
activities, the activities identified as non-clinical are those performed by ACNPs
with or for nursing or other organizationally based staff. The clear identification
of the ACNPs non-clinical activities is important to highlight, because such activ-
ities have a strong clinical focus and contribute to improvements in the quality of
patient care as well as provider and system outcomes.
Key Issues and Challenges
revealed four factors consistently identified as affecting the full integration of the
ACNP into the Canadian healthcare system: (1) full utilization of role compo-
nents, (2) scope of practice, (3) team acceptance and (4) funding issues.
Full Utilization of Role Components
Many ACNPs have difficulty integrating all components of their advanced prac-
tice nursing role, given their heavy patient care responsibilities (DAmour et al.
2007). For example, in Quebec, it is recommended that 70% of ACNP work time
be spent in clinical activities and 30% in non-clinical activities such as education,
leadership and research (OIIQ and CMQ 2006d). Our interviews with ACNPs,
regulators, healthcare administrators and physicians illustrated the different
expectations regarding the amount of time spent in each role component. For
ACNPs, adding the non-clinical functions to a heavy patient care load tended to
create high or unrealistic expectations, and confusion with the CNS role in the
organization. Regulators noted a discrepancy between the expectations of health-
care administrators and hospital physicians regarding the amount of time ACNPs
spent in direct patient care. Physicians wanted the ACNPs time devoted mainly or
exclusively to clinical practice, whereas healthcare administrators wanted ACNPs
to also have some protected time to engage in leadership, research and education
activities and, in so doing, be more aligned with nursing and supportive of nurses
within the organization. The following quotes illustrate these various perspectives.
A regulator interview participant noted:
For directors of nursing, given that these nurses are experts in their field,
they would want to use them extensively for nurse development, and I
would tell you this even occasionally creates conflicts with the physicians,
who would like to have the [ACNPs] with them more often and less often
teaching nurses, lets say. They would want them working more with
clients, performing medical procedures.
A healthcare administrator interview participant stated:
They are delivering excellence in clinical care, personally working well
with the team, with other interdisciplinary team members as well, but
they have not been making as strong a contribution to the science of nurs-
ing, or to the development of the practice of nursing and certainly not to
the development of the system.
One ACNP interview participant noted:
How do you find protected time to do things [non-clinical role compo-
nents]? In our contract, within our job description, what we agreed on as
an institution [was that] we should have one day as protected time. How
do you operationalize that [non-clinical role components]? Its difficult to
operationalize in this clinic setting where I work, so basically that is stuff I
do at home.
Another ACNP interview participant identified that a facilitator to full utilization
of role components was adequate coverage for clinical responsibilities:
I think I am able to implement all the parts. I have just completed two
research projects; they are both written up for publication. I am involved
in education. Im involved in some administration because I am one of
the people that does the assignments for the neonatal NPs and then the
80% on the unit. But there are enough of us that we cover each other, and
we are now at full complement after all of these years. We are up to the
number of NPs that we need to run the unit, to cover the unit 24 hours a
day, 7 days a week.
These concerns about role utilization are not new. At the time of its introduction
in 1986, the role title used for the ACNPs in neonatology was CNS/NP. This
was chosen to reflect the need for nurses to develop the non-clinical compo-
nents of the ACNP role in addition to technical and patient management skills
(Hunsberger et al. 1992). The title CNS refers to registered nurses who have
a graduate degree in nursing and expertise in a clinical nursing specialty (CNA
2009a). CNS and ACNP roles share a number of similarities. Both require educa-
tion at the graduate level. CNS roles include clinical practice, consultation, educa-
tion, research and leadership (CNA 2009a). According to Schreiber et al. (2005b),
the CNS promotes evidence-based practice, acts as a mentor and role model for
staff nurses, and is involved in the hiring and orientation of new personnel. In
addition, Canam (2005) highlights the contribution of CNSs to health services
delivery at the policy and population level. An in-depth discussion of the differ-
ences between these roles can be found in Donald et al. (2010a) in this special
issue. In our interviews, CNS/NPs self-identified as ACNPs and believed the term
CNS/NP was no longer necessary to fully implement all the components of their
advanced practice nursing role.
The literature and interviews identified that role expectations can be enhanced by
strong leadership from healthcare managers that includes facilitating collabora-
tion among ACNPs, physicians and nurses (Irvine et al. 2000; Roschkov et al. 2007;
Sarkissian and Wennberg 1999; Schreiber et al. 2005b; van Soeren and Micevski
2001). Reay et al. (2003, 2006) explored managers roles and perspectives when
introducing an ACNP role into the healthcare team and found that nurse manag-
ers faced three major challenges: task reallocation, the management of altered
working relationships, and ongoing management of the team in an evolving situ-
ation. To effectively implement the ACNP role, managers need to facilitate a clear
vision for the ACNP role, communicate with groups involved with the ACNP and
support the role within the organization (Reay et al. 2003, 2006).
Communication that clearly articulates ACNP role expectations aids role imple-
mentation (van Soeren and Micevski 2001). The development of detailed written
job descriptions (Cummings et al. 2003) and ACNP involvement in their devel-
opment (Nhan and Zuidema 2007) are helpful strategies that enhance job satis-
faction. Ongoing discussions between managers and team members promote a
greater understanding of the ACNP role (Wall 2006) and help stakeholder groups
develop clear expectations of the ACNP role (Rosenthal and Guerrasio 2009).
Tailoring the message about ACNP roles to the needs of each stakeholder group
facilitates their integration into the healthcare team (Cummings et al. 2003). For
example, by considering the priorities and key questions of physician stakeholders
(e.g., standards of care and competence), the appropriate scientific evidence on
outcomes can be presented (Cummings and McLennan 2005). Some stakeholders
may be most interested in the cost-effectiveness of the role, while others will want
to see evidence of how the ACNP benefits organizations striving to meet escalat-
ing patient needs, including the timeliness of patient care delivery (Harwood et
al. 2004). An in-depth discussion of leadership and APN roles can be found in the
article by Carter et al. (2010) in this special issue.
Scope of Practice
Scope of practice refers to the activities that members of a profession are
educated and authorized to perform (Davies and Fox-Young 2002; Oelke et al.
2008). Activities included in the ACNP scope of practice differ across specialties
(Hunsberger et al. 1992; OIIQ 2009). Depending on jurisdictional and institu-
tional regulations, the extension of activities beyond the scope of practice of the
registered nurse may require delegation of tasks using protocols, medical direc-
tives and drug lists (Keizer et al. 2000; MacDonald et al. 2005; OIIQ and CMQ
2006d; Vlasic et al. 1998). Medical directives are developed within organizations
in collaboration with physicians, administrators, ACNPs and other members of
the healthcare team to specify the requirements and conditions for such activities
(CNO 2009b; Ordre des pharmaciens du Qubec [OPQ], 2007). Once accepted
by the appropriate medical advisory board or similar authority in the organiza-
tion, the directives provide legal authority to ACNPs to prescribe medications, and
order treatments and tests (Nurse Practitioners Association of Ontario [NPAO]
2007; OPQ 2007). The use of protocols or drug lists allows ACNPs to work auton-
omously within the parameters defined by the medical directives (Harwood et al.
2004), which expedites care delivery by eliminating the need to wait for a physi-
cians approval of the plan of care (Hurlock-Chorostecki et al. 2008).
The development of medical directives is complex and onerous (DAmour et al.
2009; Hurlock-Chorostecki et al. 2008; OPQ 2007; Schreiber et al. 2005b), and
some physicians are uncomfortable with the responsibility and liability associated
with medical directives (DAmour et al. 2009). Physician and healthcare admin-
istrator interview participants talked about the substantial amounts of time it
takes to develop the detailed directives, which could be out-of-date before they are
approved. The use of directives could lead to decreased quality of care, untimely
access to care, blurred accountability for care, and ACNP dissatisfaction with
workload and the quality of care (Hurlock-Chorostecki et al. 2008; NPAO 2007;
OIIQ 2009; Roschkov et al. 2007).
The involvement of physicians in the development of medical directives is impor-
tant (DAmour et al. 2009; OIIQ 2009) and may facilitate collaboration among
professions (Jones and Way 2004; Mundinger et al. 2000; Shapiro and Rosenberg
2002). Certain structures maintain a high level of physician control over the activi-
ties that are performed by ACNPs and other healthcare providers (DAmour et al.
2009; Hurlock-Chorostecki et al. 2008; Patterson et al. 1999; Roots and MacDonald
2008; Vlasic et al. 1998). Particularly problematic structures were those that
required physician approval at all levels of the ACNP role implementation proc-
ess and extensive physician involvement in ACNP decisions about patient care,
follow-up and referrals (DAmour et al. 2009). Although the policies in healthcare
organizations may support the principle of collaboration when developing ACNP
roles, in actuality physicians have the final say on whether or not they will accept
ACNP-related policies in their day-to-day practice (DAmour et al. 2007). This
affects the ability of ACNPs to work to their full scope of practice (McNamara et
al. 2009). In Quebec, the lack of agreement between licensing boards about ACNP
scope of practice and the scope of the medical directives created additional barriers
to the development of collaboration between physicians, ACNPs and pharmacists,
and impeded the development of medical directives (Desrosiers 2009; DAmour et
al. 2007, 2009; McNamara et al. 2009; OIIQ 2009).
In our interviews, healthcare administrators, government informants, regulators,
physicians and ACNPs also identified barriers such as the lack of ACNP admission
and discharge privileges, prescribing authority issues, and the difficulties ACNPs
experienced with referring to specialists in some jurisdictions. With respect to
prescribing privileges, the issues differed by jurisdiction, but examples included
problems with prescribing according to drug lists, lack of prescribing authority for
hospital-based NPs and resistance from pharmacists. Interview participants high-
lighted the need to update regulatory frameworks to reflect current practice reali-
ties, and the importance for all healthcare providers to clearly understand their
respective responsibilities when providing patient care services.
Some jurisdictions have introduced regulations that support a broad scope of NP
practice, and others have worked to overcome restrictions in scope of practice. In
2005, the College of Registered Nurses of British Columbia developed a regulatory
framework that established a broad scope of practice for NPs in different settings
that does not require physician supervision (Wearing et al. 2010). The nursing
regulatory body establishes the limits and conditions of practice. More recently,
Ontario passed Bill 179, which will do away with the existing lists for prescribing
and ordering diagnostic and laboratory tests (MoHLTC 2009a).
Team Acceptance
Physician and ACNP interview participants identified factors that support NP role
implementation including having positive, respectful and trusting relationships
between physicians and NPs, good communication, a willingness to deal with
conflict, the right organizational structure and matching of the right personalities.
A physician we interviewed noted that if everybody feels theyre getting more out
of it than theyre losing, then its going to be successful, and by working together
the ACNP and physician could provide better services and ensure patients do not
fall through the cracks. A medical specialist stated:
If a nurse practitioner tells me something, Im going to listen to that. And
she may not always be right and I may not always be right, but Im going
to listen because shes got that experience.
Findings regarding nurses views of ACNP roles appear mixed. DAmour et al.
(2007) reported that in Quebec bedside nurses were concerned with the increas-
ing hierarchy within the nursing profession following the recent introduction
of ACNP roles. Other researchers (Harwood et al. 2004; Mitchell-DiCenso et al.
1996b) found that nurses had positive views of the ACNP role in the healthcare
team because ACNPs are a source of patient information, deal with team member
concerns about patients in a timely manner, improve communication among
team members, and provide consistency in patient care because they remain on
the units and are not subject to rotation. It may be that nurses perceptions are
related to the length of time they are exposed to ACNPs, as some studies have
shown that, over time, nurses are no longer concerned they will be replaced by
ACNPs (Irvine et al. 2000) and they appreciate the ACNPs role as a resource
(Cummings et al. 2003; Jensen and Scherr 2004; MacDonald et al. 2005). An RN
interview participant stated:
I think having the ACNP in the unit makes a huge impact. Nursing staff
can get their smaller problems dealt with earlier, quicker, first thing in the
morning. They dont have to wait till the end of the day, or if they have
a question they can ask her and its not wasting her time, so thats great.
I think families and patients have that face, that person, that contact,
whereas normally the surgeons are in the ORs [operating rooms] all day.
The healthcare team informants in our synthesis talked about turf wars as team
members renegotiated their roles, and noted that lack of written information
about ACNP credentialing, scope of practice and drug formulary approvals
created uncertainty and confusion about the role. Some team members feared
their roles would be replaced by the ACNP. The literature highlighted that in acute
care settings, medical residents expressed concern about losing control of patient
care decisions and having to compete with ACNPs for opportunities to perform
medical activities (DAmour et al. 2007; Fdration des mdecins rsidents du
Qubec 2003a, 2003b, 2003c, 2004). Mitchell-DiCenso et al. (1996b) found that
all respiratory therapists surveyed in their study reported a diminished quality in
their worklife following the introduction of the neonatal ACNP role. A healthcare
team member noted:
Well, I think its making sure that you involve the healthcare professionals
that are going to be working very closely with either the CNS or the NP. I
think thats the key issue involved, whether its a physiotherapist, respira-
tory therapist and the nurses too, themselves. I know that at the beginning
even the bedside nurses were having some issues. A lot of them felt, well
youre a nurse and Im a nurse why should I be taking orders from you?
Sort of this little power struggle during the first year, and once things sort of
settled in and everybody understood what everybody was doing and every-
body understood also the level of training that they have received, that put
things in perspective, and then things fell into place. So number one, I think
involvement of the healthcare professionals obviously is very important.
The overlap of roles may be greater between CNSs and ACNPs in the same
specialty, given that they both have graduate-level education and share care coor-
dination functions (Sarkissian and Wennberg 1999; Sidani et al. 2006a, 2006b;
Williams and Sidani 2001). Griffiths (2006) described CNS and ACNP roles in
one clinical setting and highlighted the importance of clearly defining and articu-
lating each role and its scope of practice. Informants in our synthesis identified
co-location of CNSs and ACNPs as a way of facilitating the development of
complementary roles within a specialty. Co-location brings people together in
a physical space (Kahn and McDonough 1997) and has been found to improve
patient adherence to treatment plans and staff member education (Knott et al.
2006), facilitate the development of a common understanding and improve work
coordination (Hudson et al. 1997; Reddy et al. 2001). However, co-location of
CNSs and ACNPs may also increase role confusion if providers do not have suffi-
cient time to examine and understand each others roles (Griffiths 2006).
Funding Issues
The lack of stable funding in global hospital budgets for ACNP roles and the
insufficient salaries for ACNPs have consistently been identified in the literature
as barriers to implementing and sustaining these roles (CNA 2006; Cummings
and McLennan 2005; DAmour et al. 2007; Desrosiers 2007; Irvine et al. 2000;
Patterson et al. 1999; OIIQ 2009; Roots and MacDonald 2008; Rseau qub-
cois de la cardiologie tertiaire 2003; Roschkov et al. 2007; Schreiber et al. 2005a,
2005b). These same issues were raised by many of the interview participants. The
lack of physician remuneration to supervise ACNP practice and the reduction in
physician remuneration, if their income is tied to the number of patients they see
(fee-for-service) (Gosselin 2001), have also been identified as barriers to the devel-
opment of ACNP roles. One regulator we interviewed said:
What is also unclear is all the financial support to implement a new nurs-
ing role; at present, the support is fairly minimal, whether for nurses
studying to be trained as nurse practitioners, or for the clinical settings
that subsequently hire them, where the support is minimal and lasts for
only two years, after which these settings must be self-funding.
DAmour et al. (2007) reported that ACNP salaries are insufficient, and govern-
ment funding does not adequately cover the large investments required by univer-
sities and healthcare organizations to train students. Healthcare administrator
and ACNP interview participants were concerned that the diminished earning
potential for these roles poses a barrier to recruitment of ACNPs, and salary ineq-
uities make it difficult for some jurisdictions to retain ACNPs. According to ACNP,
healthcare administrator and regulator interview participants, most ACNPs are
not part of the nursing union, and even when they are, the poor fit between the
role and the union means that they do not have suitable bargaining rights regard-
ing issues such as salary increases, wage disparities, benefits and working condi-
tions. A number of authors (CNA 2006; DAmour et al. 2007; OIIQ 2009) have
questioned the long-term survival of ACNP roles, without stable funding schemes
for these positions and salaries that clearly recognize their scope of practice and
level of responsibility. Participants in the CHSRF roundtable discussions echoed
the need for stable and sustained funding for advanced practice nursing positions
once they have been successfully incorporated into the healthcare delivery organi-
zation (DiCenso et al. 2010b).
Discussion
This paper provides a description of the current status of ACNP roles and
summarizes the key issues influencing the full integration of this role into
the Canadian healthcare system. The number of ACNPs appears to be
increasing in Canada. There have been difficulties with accurate tracking of
the role, but these will be resolved as more jurisdictions establish their licens-
ing and registration processes for ACNPs.
Important differences were noted in the way ACNP roles were implemented
in the healthcare system. The requirement for medical directives by many
organizations has led to frustration for providers and highlighted the politi-
cal nature of delegating prescribing authority to ACNPs (McNamara et al.
2009). Consistent support from physicians, healthcare administrators and
leaders is essential for the development of clear role expectations for ACNPs
to enact all their role components. Clear, consistent legislation across all
provinces and territories would support the full utilization of role compo-
nents, facilitate interprofessional collaboration and enable ACNPs to func-
tion autonomously to their full scope of practice.
There appears to be a tug-of-war between the health care managers support
for the non-clinical components of the ACNP role and physicians needs for
a full-time clinical care provider. An important added value of the ACNP
role in healthcare teams lies in the ability of ACNPs to enact both the clini-
cal and non-clinical components of their role, including education, leader-
ship and research. Stakeholder involvement in the development of ACNP
roles needs to occur as early as possible in the process of role development
to foster an agreement about expectations (Bryant-Lukosius and DiCenso
2004). Healthcare managers play a central role in the implementation and
full utilization of ACNP roles (Carter et al. 2010). They help identify the
expectations of the role, collaborate on written agreements that outline
ACNP activities (Madgic and Rosenweig 1997), help to develop a mutual
understanding of ACNP role components to align with expectations (Knaus
et al. 1997) and facilitate role implementation for all those involved.
This study highlighted the need for more emphasis on the development of a
research component for ACNP roles as a hallmark for any advanced practice
nursing role. However, in the context of a high clinical workload and time
pressures, this component remains difficult for ACNPs to implement. A
focus on the research component was evident in the literature and interviews
related to the CNS role but not as evident in the literature and interviews
for NP roles (Bryant-Lukosius et al. 2010; Donald et al. 2010b). As managers
play a critical role in ACNP role implementation, they may be able to facili-
tate the involvement of ACNPs in research activities. Such activities could
include advancing the profession through conducting original research,
critiquing and using research evidence in ACNPs practice, collaborating
in research studies, recruiting study participants or disseminating research
findings to colleagues. It is likely that ACNPs are already applying research
findings to practice and disseminating findings to colleagues, but the extent
of these research activities is not known and requires further study.
Co-location of ACNPs with other team members, particularly CNSs, is a
helpful strategy for role implementation, but it has received little attention
in the healthcare literature. Humbert et al. (2007) suggest that co-location of
primary healthcare NPs and members of the healthcare team can decrease
professional isolation and may facilitate team integration. The proximity of
team members makes it easier to communicate and develop good working
relationships and facilitates collaboration (Knott et al. 2006). Collaboration
among professionals may be an effective way to preserve the essential char-
acteristics of each team members role (Beaulieu et al. 2008) and facilitate
Acknowledgements
working to full scope of practice (CHSRF 2006; Oelke et al. 2008). Time
appears to be an important consideration in order for ACNPs and team
members to have an opportunity to reflect on their roles within the team
and develop different aspects of their roles (Kilpatrick 2008).
Short-term funding for ACNP positions does not ensure the sustainability
of the role to address patient needs. Stable and predictable funding mecha-
nisms for the implementation and ongoing development of ACNP roles
were identified in the roundtable discussions as important to the long-term
sustainability of these roles (DiCenso et al. 2010b). Remuneration mecha-
nisms that do not disadvantage the physician or the ACNP enable them to
work collaboratively and efficiently to achieve patient benefits.
Finally, the scoping review used a variety of search terms and different search
strategies to locate the literature related to advanced practice nursing roles.
However, to the best of our knowledge, no study has focused primarily on
the interprofessional relationships between ACNPs and members of the
healthcare team. This needs to be explored in greater depth, because some
members of the healthcare team described turf wars and dissatisfaction with
the integration of ACNP roles. Nevertheless, perceptions of ACNP roles by
members of the healthcare team appear to be improving.
Conclusion
In summary, we found that the number of ACNPs in most Canadian jurisdic-
tions is increasing. Key issues identified in our synthesis where improvement
is needed for ACNP roles to be fully integrated into the Canadian health-
care system include utilization of non-clinical role domains, consistency in
implementing full scope of practice across all jurisdictions, team accept-
ance and collaboration within the healthcare team, and secure funding and
competitive salaries for ACNPs. The evidence from the sources used for this
scoping review (literature, key informant interviews and roundtable discus-
sions) supports an encouraging evolution of the ACNP role in Canada; this
evolution will require ongoing nursing leadership and continuing research to
enhance the integration of these roles into our healthcare system.
Charbonneau-Smith, R. James McKinlay, Dianna Pasic, Julie Vohra, Rose Vonau
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140
The Clinical Nurse Specialist
Role in Canada
Assistant Professor, School of Nursing and Department of Oncology, McMaster University
Senior Scientist, CHSRF/CIHR Chair Program in Advanced Practice Nursing (APN)
Hamilton, ON
Hamilton, ON
St-Jrme, QC
Associate Professor and Associate Director, Graduate Programs, School of Nursing,
Dalhousie University, Halifax, NS
Associate Professor, Daphne Cockwell School of Nursing, Ryerson University, Toronto, ON
Hamilton, ON
Oakville, ON
Ivy Bourgeault, PhD
Ottawa, ON
141
Abstract
The clinical nurse specialist (CNS) provides an important clinical leadership role
for the nursing profession and broader healthcare system; yet the prominence and
deployment of this role have fluctuated in Canada over the past 40 years. This paper
draws on the results of a decision support synthesis examining advanced practice
nursing roles in Canada. The synthesis included a scoping review of the Canadian
and international literature and in-depth interviews with key informants including
CNSs, nurse practitioners, other health providers, educators, healthcare adminis-
trators, nursing regulators and government policy makers. Key challenges to the
full integration of CNSs in the Canadian healthcare system include the paucity of
Canadian research to inform CNS role implementation, absence of a common vision
for the CNS role in Canada, lack of a CNS credentialing mechanism and limited
access to CNS-specific graduate education. Recommendations for maximizing the
potential and long-term sustainability of the CNS role to achieve important patient,
provider and health system outcomes in Canada are provided.
Director, Ontario Training Centre in Health Services and Policy Research
Professor, Nursing and Clinical Epidemiology and Biostatistics, McMaster University
Hamilton, ON
Introduction
Since the late 1960s, the clinical nurse specialist (CNS) has played a prominent role
in the Canadian healthcare system (Canadian Nurses Association [CNA] 2006a;
Davies and Eng 1995; MacDonald et al. 2005; Montemuro 1987). CNSs were intro-
duced to support and improve the quality of nursing care at the bedside in response
to increasing specialization, technology, patient acuity and the complexity of
healthcare. Clinical expertise in a specialized area of practice is characteristic of the
CNS role (CNA 2009; National Association of Clinical Nurse Specialists [NACNS]
2004). As an advanced practice nursing role, the CNS is envisioned as a multidi-
mensional clinical role based on the principles of primary healthcare and with a
focus on health, health promotion and patient-centred care (CNA 2008, 2009).
In addition to specialized clinical expertise, the CNS has a graduate degree in
nursing and provides an advanced level of nursing practice through the integra-
tion of in-depth knowledge and skills as a clinician, educator, researcher, consult-
ant and leader (CNA 2009; Clinical Nurse Specialist Interest Group [CNSIG]
2009). CNSs have responsibilities for patient care and for promoting excellence in
nursing practice by educating and mentoring other nurses, generating new nurs-
ing knowledge, promoting the uptake of research into practice, developing and
implementing new practices and policies, providing solutions for complex health-
care issues and leading quality assurance and change initiatives (CNA 2009).
Through innovative nursing interventions, the CNS role has the potential to make
a significant contribution to the health of Canadians by improving access to inte-
grated and coordinated healthcare services (CNA 2009). However, the profile and
deployment of CNS roles across the Canadian healthcare landscape have fluctu-
ated over the past 40 years and the full benefit of the role has yet to be realized
(CNA 2006a, 2009).
The purpose of this paper is to examine the CNS role in terms of its current status
in Canada; education; regulation and scope of practice; supply, deployment and
practice settings; and role outcomes. Key issues and challenges influencing role
integration and long-term role viability are identified and recommendations to
address these challenges are summarized.
Methods
This paper is based on a decision support synthesis (DSS) that was conducted to
develop a better understanding of advanced practice nursing roles, their current
use, and the individual, organizational and health system factors that influence
their effective development and integration in the Canadian healthcare system
(DiCenso et al. 2010a). A DSS combines research and knowledge translation strat-
egies to summarize and integrate information and provide recommendations on a
specific healthcare issue (Canadian Health Services Research Foundation [CHSRF]
2009). It generally includes a synthesis of published and grey literature and, when
appropriate, may include data collected from key informants. DSSs use deliberative
strategies to engage decision makers in formulating questions, framing the project
scope and reviewing the draft report to generate recommendations (CHSRF 2009).
An earlier paper in this issue provides a detailed description of the methods for
this synthesis (DiCenso et al. 2010b). In brief, it included a comprehensive exami-
nation of published and grey literature on Canadian advanced practice nursing
roles from the time of inception and international literature reviews from 2003
to 2008. A total of 2,397 papers were identified, of which 468 were included in
the scoping review. Interviews (n = 62) and focus groups (n = 4 with a total of 19
participants) were also conducted with national and international key informants
including CNSs, nurse practitioners (NPs), physicians, other health providers,
educators, healthcare administrators, nursing regulators and policy makers.
A structureprocessoutcome framework relevant to advanced practice nursing
(APN) role implementation was used to develop a data extraction tool and data-
143 The Clinical Nurse Specialist Role in Canada
base for the literature review and to create a semi-structured guide for the inter-
views and focus groups (Bryant-Lukosius and DiCenso 2004; Bryant-Lukosius et
al. 2004). Data related to structures included policies, education, and the human,
physical, practical and information resources known to be important for APN role
implementation. Information about processes related to where, what and how
APN roles were enacted. Outcome data referred to the impact of APN roles on
patients, providers and the health system. Possible solutions to improve the inte-
gration of APN roles were also identified.
Four research team members were assigned CNS publications to review and
extract information that was entered into a database. Using printouts of the
extracted data, each reviewer provided a summary report on their publications. At
a team meeting, each report was examined and discussed to compare and contrast
themes and to formulate conclusions about the data as a whole.
The semi-structured interview and focus group guide asked key informants about
their knowledge and experience with different types of APN roles, including the
CNS. All key informants were asked the same questions, some of which related
to the CNS role. Participants were asked to describe how CNS roles were imple-
mented in their organization and/or jurisdiction, to provide examples of promis-
ing models of CNS practice and CNS role outcomes, and to identify barriers, facil-
itators and solutions to enhancing CNS role integration. A team of four reviewers
analyzed and summarized the interview data. Content analysis of the transcribed
audiotaped interviews was conducted using an agreed-upon coding scheme and
documentation form to identify themes related to APN role structures, processes
and outcomes. A spreadsheet was used to summarize codes, themes and data from
each transcript so that themes about CNS and other APN roles could be compared
across the transcripts. All interview and focus group data specific to CNS roles
were included in the analysis for this paper. To synthesize the literature and
interview/focus group data, the similarities and differences in themes, common
patterns and trends, and implications for the CNS role from both data sets were
compared and summarized in relation to current status in Canada; education;
regulation and scope of practice; supply, deployment and practice settings; role
outcomes; and challenges to role integration.
When the synthesis was completed, CHSRF convened a multidisciplinary round-
table to develop recommendations for policy, practice and research based on the
synthesis findings. For this paper, we have focused attention on interview and
focus group data, descriptive reports, primary studies and reviews about the CNS
role in Canada, as well as related roundtable recommendations. We have drawn on
international literature to provide global context and for further discussion about
key issues when relevant.
Results
The CNS-related papers contributed 9.7% (34/349) of the Canadian papers
included in the synthesis. The 34 papers consisted of 19 essays and 15 reports
of primary studies (DiCenso et al. 2010b). Table 1 summarizes these 15 articles
(4 are based on the same study). Most studies were conducted at single sites or
institutions in a western province between 2003 and 2006 and employed qualita-
tive and descriptive research methods. None investigated CNS practice across the
country. One third of the studies examined a mix of CNS roles in various special-
ties, and the remaining studies focused on CNS roles in specific specialties such
as pediatrics, cardiology, neonatology, medicine and geriatrics. We begin our
presentation of the findings with a summary of key contextual issues related to the
CNS role, followed by the issues and challenges that most frequently and consist-
ently emerged from our data analysis: the paucity of Canadian research on the
CNS role, absence of a common vision for the CNS role in Canada, lack of a CNS
credentialing mechanism and limited access to CNS-specific graduate education.
Table 1.
Canadian CNS role studies between 1950 and 2008
Author Year Study design
Area of specialization
or practice Location
Alcock 1996 Descriptive Mixed Ontario
Canam 2005 Qualitative Pediatrics British Columbia
Carr and Hunt 2004 Program evaluation Geriatrics British Columbia
Charchar et al. 2005 Qualitative Cardiac Quebec
Davies and Eng 1995 Descriptive Mixed British Columbia
Forster et al. 2005 Randomized
controlled trial
Acute medicine Ontario
Hogan and
Logan
2004 Descriptive/program
evaluation
Neonatal Ontario
Lasby et al. 2004 Program evaluation Neonatal Alberta
Pauly et al.
a
2004 Descriptive
qualitative
Mixed British Columbia
Pepler et al. 2006 Qualitative/program
evaluation
Oncology and
neurology
Quebec
Profetto-
McGrath et al.
2007 Descriptive Mixed Western health
region
145
Schreiber et
al.
a

2003 Descriptive Mixed British Columbia
Schreiber et
al.
a
2005
a
Descriptive
qualitative
Schreiber et
al.
a
2005 Descriptive
qualitative
Smith-Higuchi
et al.
2006 Qualitative Geriatrics Western health
region
a
Four publications about the same study.
CNS= Clinical nurse specialist
Current Status of the CNS Role in Canada
The CNA (2009) defines a CNS as a registered nurse who holds a masters or
doctoral degree in nursing and has expertise in a clinical nursing specialty. The
most recent position statement on the CNS reaffirms the multidimensional
nature of this role, with integrated responsibilities for clinical practice, education,
research, consultation and leadership (CNA 2009). The multi-faceted aspects of
this role were also reported in the literature and by key informants familiar with
the CNS role. Healthcare administrators and physicians perceived the CNS role as
more varied than the NP role, with more involvement in supporting other health
providers and leading education, evidence-based practice, quality assurance and
program development activities. Healthcare administrators identified that the
strength of CNSs was their ability to blend clinical expertise with leadership and
research skills to support administrative decision making and to achieve academic
agendas in teaching hospitals. One healthcare administrator explained:
They [CNSs] have broad responsibilities in quality development, nurs-
ing leadership, program development, administration, practice, research
and education they are very valued contributors as a nursing leader-
ship role and as a role model and mentor for clinical practice. And [they]
participate actively in our academic agenda as well.
A multiple-case study documented a number of ways CNSs promoted research-
based nursing practice. This involved questioning current practice and develop-
ing researchable clinical questions, conducting research and engaging staff in the
research process, meeting learning needs through mentorship and education,
building on staff expertise, managing resistance to change and through publi-
cations and presentations (Pepler et al. 2006). CNSs also use varied sources of
evidence to influence decision-making at the bedside and at administrative levels
(Profetto-McGrath et al. 2007). CNSs report that their research, education and
Table 1 Continued.
administrative knowledge and skills are necessary to effect change and improve
patient care at the individual, unit and organizational levels (Pauly et al. 2004;
Schreiber et al. 2005a). In one qualitative study, pediatric CNSs described how
they intervened at several levels, including the patient, patient populations, nurses
and other health providers, and the health system (Canam 2005). Interview and
focus group participants also concurred that CNS interventions were systems
oriented, population focused and staff targeted.
CNSs work in various specialties that may be defined by type of illness, such as
cancer or cardiovascular disease (Griffiths 2006; Ingram and Crooks 1991); health
needs, such as pain management (Boulard and Le May 2008); type of care, such
as palliative or critical care (Peters-Watral et al. 2008; Urquhart et al. 2004); or by
patients age, for example, pediatrics, neonatology or gerontology (Canam 2005;
Lasby et al. 2004; ORourke et al. 2004; Smith-Higuchi et al. 2006).
Interview participants agreed that CNS roles were the least understood of all
advanced practice nursing roles (Donald et al. 2010). The multiple dimensions of
the role and the varied ways CNSs implemented their roles contributed to poor
role clarity and may explain why CNSs felt they were viewed as a jack of all trades.
Another factor is the lack of clarity about the nature of the clinical component of
the role. A nurse regulator interviewed for the synthesis highlighted this issue:
In my view the ideal CNS role is of a clinical expert is to facilitate and
foster the development of excellence in colleagues. Others see the role
as solely developing a niche expertise in a clinical area for the purpose of
direct care delivery.
Most of our study participants felt that CNS roles had limited involvement in the
direct clinical care of patients. Notable exceptions were in oncology and palliative
care, where CNSs had extensive clinical roles in pain and symptom management
and care coordination. In contrast, Canadian studies described a number of ways
CNSs were involved in direct patient care, including the assessment and manage-
ment of acute and chronic illnesses, health promotion, discharge planning, care
coordination and education (Bryant-Lukosius et al. 2007; Canam 2005; Charchar
et al. 2005; Lasby et al. 2004; Schreiber et al. 2003). Interview participants observed
that CNSs without a direct clinical role were more vulnerable to funding cutbacks
because the loss of the role may not have immediate impact on practice settings.
Lack of clarity about the clinical component also makes it difficult to distinguish
CNSs from other types of nursing roles. Interview participants identified difficul-
ties in knowing when to recruit a CNS versus an NP in acute care settings. Several
studies reported role confusion (Canam 2005; Smith-Higuchi et al. 2006) and role
overlap with masters-prepared nurse educators (Pepler et al. 2006; Wall 2006).
147
Education
The recommended education for advanced practice nurses in Canada and inter-
nationally is a masters degree from a graduate nursing program (CNA 2008;
International Council of Nurses 2008). While data are collected regularly about
NP education programs in Canada (Canadian Association of Schools of Nursing
[CASN] and the CNA 2008), information about graduate nursing education
programs to prepare CNSs in Canada is not routinely gathered. To identify existing
CNS-related education courses and/or programs, we reviewed the websites of grad-
uate nursing programs in Canada and collaborated with the CASN to survey these
31 programs. Of the 31 programs, 27 responded to the survey. Based on combined
website and survey data, one of 31 programs offered a CNS-specific program, but
enrolment to this program was closed due to lack of funding, a second program
offered an advanced practice leadership option to prepare CNSs and clinical lead-
ers and a third program was exploring the possibility of developing a CNS stream.
Another program offered two CNS-specific courses, and six programs offered
general advanced practice courses that could be relevant to but were not specifi-
cally designed for CNSs. The types of courses varied among graduate programs but
focused on developing clinicians, educators, leaders and/or researchers to practise
at an advanced level. The limited access to CNS-specific graduate education in
Canada is a key issue challenging CNS role integration and is discussed later in this
paper and in another paper in this special issue (Martin-Misener et al. 2010).
Regulation and Scope of Practice
In Canada, the scope of practice for the CNS is the same as that of the registered
nurse, and to date, most provinces or territories do not have additional legisla-
tion or regulation for this role. In Alberta, the title of Specialist is restricted to
registered nurses who are practising in a specialty, with a graduate degree that is
relevant to the area of practice and three or more years experience in the specialty
(College and Association of Registered Nurses of Alberta 2006). However, the
title Specialist is not limited to CNS roles and can be applied to other advanced
practice nursing roles. In Quebec, NPs in primary care, neonatology, nephrology
or cardiology who have completed a specialist certificate in addition to masters
education can call themselves specialists (Gouvernement du Qubec 2005). These
specialist certificates are not available for CNSs and thus the title, CNS, is not
formally recognized.
None of our interview participants identified CNS involvement in extended role
activities outside the scope of nursing practice. However, in one province, CNSs,
particularly those in rural and remote settings, provide some medical role func-
tions. Authority for these extended practice activities occurs through formal
and informal transfer of function agreements with physicians, clinical protocols,
orders or organizational policies (Schreiber et al. 2005a).
Supply, Deployment and Practice Settings
An accurate assessment of the current number of CNSs in Canada is not possible
because of the lack of standardized regulatory and credentialing mechanisms to
identify those who qualify as CNSs and the absence of provincial or national proc-
esses to track these roles. The data are based on nurses who self-identify as CNSs,
even though they may not have the recommended graduate education or specialty
preparation for the role. Based on these self-reports, between 2000 and 2008 the
number of CNSs declined from 2,624 to 2,222 and accounted for about 1% of the
Canadian nursing workforce (Canadian Institute for Health Information [CIHI]
2010; CNA 2006b). The greatest drop in CNS numbers occurred in Ontario
and British Columbia, but there was a modest rise in the number of CNSs in
Newfoundland, Nova Scotia, Quebec and Saskatchewan.
Key informant perceptions were consistent with our findings from the literature
about the falling number of CNSs and the need for better mechanisms to moni-
tor the supply and deployment of CNS roles. When commenting on how CNSs
were utilized in their practice setting or jurisdiction, interview and focus group
participants noted that once the role was introduced it was generally well received.
However, limited data existed to support health human resource planning for the
role, and the role was not well understood or integrated into the health system. As
these policy makers and regulators explained:
I dont think it [CNS role] is really embedded into the system the same
way that NPs are.
There is an uncertainty of the real supply of CNSs in the system.
So theyre kind of like lost souls that kind of [have] ... fallen out of favour.
So its actually having a process to ensure that their role is recognized
as well, and I think thats going to take some time because first of all we
have to identify who are CNSs.
Educator and administrator participants also painted a picture about the patch-
work deployment of CNS roles, with some jurisdictions eliminating the role and
others having some role sustainability or resurgence:
The CNS role has been very alive and active in British Columbia for many
years, since probably the late 60s.
The CNS is an interesting role in that it has not always been a role the
people have always sanctioned or understood. In times of economic
crunch CNSs were laid off. So it has been an interesting role to
149
re-establish and get moving again in our region. And there are pockets of
them, and when they are there they are very effective.
During times of economic constraint, the perceived lack of CNS role impact on
the provision of clinical services made the role vulnerable to cutbacks. This NP
explained that once the roles were eliminated, they were often not re-introduced:
There has been a reduction in the CNS as a consequence of the 90s. I can
only speak to [our] region when in the early 90s many of the CNS
roles were deleted because they were seen to be extraneous to direct care.
CNSs are typically found in acute care settings such as inpatient units, critical care
units and hospital-based clinics (Alcock 1996; Davies and Eng 2005; Forster et al.
2005; Hogan and Logan 2004; Pepler et al. 2006). Recent reports document the
introduction of CNS roles in community-based practices and in assisted living
and long-term care facilities to address the unmet and specialized health needs
of underserviced populations in rural and remote settings (Health Canada 2006;
Smith-Higuchi et al. 2006). In 2005, the Office of Nursing Services for the First
Nations and Inuit Health Branch introduced 16 CNS positions across Canada
to address concerns in three key areas: maternal child health, mental health and
chronic disease/diabetes. The major drivers for introducing these roles were diffi-
culty in recruiting and retaining nursing staff in First Nations communities and the
need for enhanced clinical resources and supports for front-line nurses (Veldhorst
2006). Their responsibilities include nursing education, developing standard-
ized orientation programs, clinical and professional development and improving
communication between nursing leadership and front-line staff. A national study
of First Nations health services also identified the need for similar CNS roles for
the prevention and management of communicable diseases (Davies 2005).
A three-year project in rural western Canada led to the introduction of a CNS role
for assisted living in enhanced lodges and long-term care facilities (Smith-Higuchi
et al. 2006). The role provided specialized expertise and leadership in the care of
older adults, including coaching and guidance of professional and non-profes-
sional staff, collaborative care and consultation services for other health providers.
An administrator participant from our synthesis described the introduction of a
similar CNS role designed to transition older adults across acute and community
healthcare sectors:
We have a CNS who works in our emergency department bringing into
the emergency department the geriatric specialized care. The work that
she is doing as far as outreach to our nursing homes has been amazing
its helping to build skill sets in the nursing homes that will prevent
unnecessary hospitalization, which contributes greatly to the hospital
being able to meet the needs of the community and building capacity
within the nursing home itself for nursing care.
Outcomes of CNS Roles
Some interview participants, such as this nurse educator, were able to articulate
the value-added outcomes of CNS roles:
So the CNS really got direct improvement in nursing development and
quality of care improving the care pathways, improving continuity of
information, continuity of care. If I want to improve my care, these
are the persons who can help me. So this [the CNS role] has a very large
impact and [can act] very rapidly in the field to improve the level of care,
to improve the continuity of care and the level of evidence-based care.
Interview and focus group participants, including this administrator, identified
that the potential benefits of CNS roles were not universally well known or under-
stood by key stakeholders:
One of the key barriers to integrating the [CNS] role is that people do
not understand the contributions that they make. Big contributions to
make that role really sustainable, we really need to increase the awareness
and understanding of the value of that role ... across certainly our region,
and I think our province and I am sure across the country.
There is a growing body of international data about the effectiveness of CNS
roles, but the limited number of Canadian studies may explain the lack of aware-
ness of CNS outcomes by some interview participants. Two American authors,
Fulton and Baldwin (2004), provide the most comprehensive compilation of
international studies assessing CNS role outcomes in an annotated bibliography.
Multiple high-quality randomized controlled trials in the United States involv-
ing varied complex and high-risk patient populations consistently demonstrate
that when compared to standard care alone, patients who received CNS care can
be discharged from hospital sooner with equal or better health outcomes, fewer
hospital readmissions, higher satisfaction with care, improved health-related
quality of life and lower acute care health costs (Brooten et al. 2002). CNS home
care reduced healthcare costs and improved the quality of life and survival rates
for elderly patients following surgery for cancer (McCorkle et al. 2000). In long-
term care, patients randomized to CNS care had improved or maintained better
levels of physical and cognitive function. They also had better outcomes related to
incontinence, pressure ulcers and mental health compared to those who received
standard care (Ryden et al. 2000). CNSs also promote staff satisfaction and qual-
151
ity of care (Gravely and Littlefield 1992) and increase patient and health provider
knowledge and skills (Barnason et al. 1998; Linde and Janz 1979). They promote
patient safety and reduce complication rates (Carroll et al. 2001; Crimlisk et al.
1997), and CNSs improve patient and health provider uptake of best practices
(Patterson et al. 1995; Pozen et al. 1997).
Table 2 summarizes the results of four Canadian studies we identified that
included some kind of outcome assessment of CNS roles or CNS-led initiatives.
In terms of determining effectiveness, the evaluation methods are weak, with most
studies using descriptive post-implementation surveys (Carr and Hunt 2004;
Hogan and Logan 2004; Lasby et al. 2004). One study evaluating the effects of a
CNS role on the outcomes of hospitalized medical patients used a comparative
study design (Forster et al. 2005); however, the use of outcome measures insensi-
tive to CNS role activities may have led to the findings. These included no differ-
ences in readmission rates, deaths or adverse events between the CNS and control
groups. Despite design limitations, the pattern of results for all four studies is
similar to those reported in the international literature indicating that CNS care is
associated with improved quality of care, enhanced nursing knowledge and skills,
better patient satisfaction with care and increased patient confidence in self-care
abilities (Fulton and Baldwin 2004).
Table 2.
Canadian studies reporting CNS role outcomes
Author and
year of study CNS intervention Study design Results Comments
Carr and Hunt
2004
The purpose of the Acute
Care Geriatric Nurse Network
(ACGNN) was to enhance
nurses ability to provide
evidence-based care to acutely
ill older adults in gerontology,
medicine, psychiatry,
rehabilitation and orthopedics.
In this provincial program,
teams of CNSs travelled to 25
communities in participating
health authorities to provide
educational workshops and
mentorship.
Post workshop,
qualitative
feedback
Nurses reported feeling
renewed, reconnected
and empowered, and
more motivated to
improve their practice.
Key Issues and Challenges to CNS Role Integration
revealed four challenges limiting the full integration of the CNS role into the
Canadian healthcare system: (1) paucity of Canadian research to inform CNS role
implementation, (2) absence of a common vision for the CNS role in Canada,
(3) lack of a CNS credentialing mechanism and (4) limited access to CNS-specific
graduate education.
Paucity of Canadian Research to Inform CNS Role Implementation
Our search for research on the CNS role in Canada revealed only a small number
of primary studies or reviews ever conducted in this country. Of 158 primary
studies or reviews of advanced practice nurses, only 15 focused specifically on
Forster et al.
2005
CNS functioned as a
nurse team coordinator,
facilitating hospital care for
patients on a medical unit
by retrieving preadmission
information, arranging
in-hospital consultations and
investigations, organizing
post-discharge follow-up
visits, and checking up on
patients post-discharge with a
telephone call.
Randomized
controlled trial
(CNS group,
n = 307; control
group n = 313)
No differences in
readmissions, deaths,
or adverse events
Patient ratings of
quality of care were
higher in the CNS
group.
Incongruence
between
outcome
measures
and CNS role
may have
contributed
to lack of
differences in
study results.
Hogan and
Logan 2004
Implementation of a research-
based family assessment
instrument developed by a
CNS and application of the
Ottawa Model of Research
Use to guide the piloting of
the assessment instrument
with members of a neonatal
transport team.
Formative
evaluation
using a post-
implementation
survey
Improved team
member perceptions
of knowledge, family
centredness and ability
to assess and intervene
with families.
Lasby et al.
2004
Neonatal transitional care
for parents going home with
low-birth-weight babies; care
delivered by a team of CNSs
and a dietician providing
in-home and telephone
support for four months after
discharge.
Post-discharge
questionnaire
completed by
parents
Lengthened breast milk
provision, decreased
demand on healthcare
resources (particularly
emergency
departments and
pediatrician offices)
and enhanced
maternal confidence
and satisfaction with
community service.
CNS=Clinical nurse specialist
Table 2 Continued.
153
the CNS role (Table 1) while, in contrast, 126 focused on the NP role (another 17
focused on the APN role in general). There have been no Canada-wide studies
of the CNS role to learn more about, for instance, the number of CNSs required
to meet healthcare needs, trends in CNS deployment, CNS practice patterns and
implementation of role dimensions (i.e., clinician, educator, researcher, consult-
ant, leader), number of vacant CNS positions and reasons for vacancy, CNS job
satisfaction, CNS education needs, and evaluation of non-clinical role dimensions
(e.g., promotion of evidence-based nursing practice). A specific recommendation
by the CHSRF roundtable was that the CNS role in the Canadian context requires
further study and should be the focus of future academic work.
Absence of a Common Vision for the CNS Role in Canada
A striking observation based on both limited national research and participant
interview data was the invisibility of CNS roles in the Canadian healthcare system.
Aside from nurse administrators, educators and CNSs, interview participants such
as physicians, regulators and government policy makers reported limited experience
and/or understanding of CNS roles. The increased visibility of NP roles in Canada
corresponds with provincial and national primary healthcare reform policies, fund-
ing of primary healthcare NP education programs and roles, and investments in
role supports such as the Canadian Nurse Practitioner Initiative (CNPI 2006; Health
Canada 2000). However, healthcare administrator, nursing regulator and govern-
ment policy maker interview participants noted that similar provincial or national
investments to support CNS roles are lacking. As a nurse regulator explained,
Theres still a lot of work to be done with the CNS role in this province
basically I dont know what to tell you about that group. Theres been so
little done in terms of developing the role and what they actually do so
in this province its not a well-developed role.
Administrators also identified the need to increase awareness and better align
CNS roles with important policy issues where CNSs can make an important
contribution:
I would like to see massive increased investment in CNS roles in practice
environments, and I think they would have a strong, positive contribution
to patient safety, quality and advancement of nursing practice.... I think
that would be an important step to successfully integrating the role.
In the 1990s, CNSs formed the Canadian Clinical Nurse Specialist Interest Group
(CCNSIG) to develop practice standards, hold annual national conferences and
produce quarterly newsletters. These activities would link colleagues from across the
country to profile and share experiences about their roles and to tackle practice and
role implementation issues (CCNSIG 1997). With the assimilation of this interest
group into the Canadian Association of Advanced Practice Nurses (CAAPN), which
represents both CNSs and NPs, the national voice of CNSs has weakened.
One challenge to organizing CNSs as a professional group is that they often align
their professional interests, activities and connections with organizations associ-
ated with their specialty field rather than with their role (CNA 2006a). This mini-
mizes their collective power and opportunity to address nursing and healthcare
issues relevant to CNS practice at provincial and national policy tables. As one
administrator described,
I think that CNSs themselves need to be maybe a little bit more vocal. NPs
were certainly more vocal so when the NP role came into the province
it got a lot of attention and the CNS role hasnt.
CNS participants identified the need for networking and national support. A CNS
interview participant notes,
Its really important for myself as a CNS to be able to meet with people in
other similar positions to talk about what are they doing, how do they
manage this, [and] how can we work together to plan some collaborative
efforts that will make a difference for the whole.
Partly to address the absence of a common vision for the CNS role, the recommen-
dation most frequently identified by the CHSRF roundtable was that the CNA lead
the creation of vision statements that clearly articulate the value-added roles of
CNSs and NPs across settings. These vision statements should include role descrip-
tions to help address implementation barriers deriving from the lack of role clarity.
Lack of a CNS Credentialing Mechanism
There is no credentialing mechanism for CNSs in Canada. As a result, nurses can
identify themselves as CNSs even if they lack the required graduate education and
expertise in a clinical specialty. Consequently, current CIHI data do not provide
an accurate indication of the number of CNSs in Canada, as defined by the CNA
(2009). Many of the interview participants, especially the CNSs, advocated for title
protection. However, this poses a significant challenge because the regulation that
would enable title protection is not required, since CNS practice does not extend
beyond the scope of the registered nurse. CNS interview participants felt that title
protection would strengthen role recognition and ensure that those in the role
have the appropriate education and experience.
155
Administrators we interviewed commented,
I dont think theres much support in policy for the regulation and legis-
lation around the CNS, and that again is a barrier to the CNS role being
implemented.
I think the CNSs are the least understood. I think with the legislation
around NPs and the protection of the title, the CNSs got lost. Everybody
sort of jumped on the bandwagon because we had legislation to protect
the NPs everyone was talking about NPs. The funding was for NPs, and
I think the CNSs got lost in that. I think people still dont understand.
The issue is further complicated by the limited access to standardized
CNS-specific graduate education in Canada, described in the next section.
Limited Access to CNS-Specific Graduate Education
As noted above, even though the recommended education for CNSs in Canada
and internationally is a masters degree from a graduate nursing program (CNA
2008; International Council of Nurses 2008), many nurses without a gradu-
ate degree self-identify as CNSs. Interview participants and one Canadian study
suggest the educational preparation of those who call themselves CNSs influences
how the role is operationalized. Pauly et al. (2004) and Schreiber et al. (2005a),
reporting on the same study, found that self-identified CNSs without a masters
degree focused their activities on the care of individual patients, while in contrast,
CNSs with a masters degree implemented their roles in a manner more consist-
ent with national standards for advanced practice (CNA 2008). They applied a
broader depth of research, education and administrative knowledge and skills to
improve patient care at the individual, unit and institutional level.
Our survey of Canadian nursing graduate programs described above revealed
that there are very few CNS-specific graduate programs. A review from the United
States indicated CNS programs there are expanding (Fulton and Baldwin 2004).
The following quotes from three APNs from different provinces convey concerns
about the absence of programs specific to the CNS role:
I have concern at the education level about how CNSs are being able to
access their education. [The university] masters program used to have
a CNS role. Now they have one course on advanced practice. They have
a whole NP program, but if you want to become a CNS, its becoming
more and more difficult to get that kind of system thinking [and] system-
support level of education to be able to understand where your role is at
the systems level.
Well, my understanding is that there arent that many masters programs that have
a CNS stream. Now, theyre being developed as an advanced practice nursing role
thats the stream. Its [CNS] no longer a clinical specialty that you develop at the
masters level of preparation, and thats unfortunate.
The key concern around the CNS role which is of grave concern to me is
the lack of specific education for the CNS role. There used to be programs
that had a very well designed course content that would prepare them for
evaluation, for project management, for the whole piece of work at the
systems level, policy, developing policy and protocols. All of those pieces
are not necessarily lumped together in a nice package so that when you
come out you can really step out in the role and fly, and in the United
States there are some of those educational programs directed for the CNS.
There were in Canada, but there arent anymore.
Specialty education is important for developing APN role confidence and job
satisfaction (Bryant-Lukosius et al. 2007) and for establishing the clinical compe-
tence and credibility necessary for successful role implementation (Richmond
and Becker 2005). Consistent with our earlier findings about the general nature
of advanced practice education provided by the majority of graduate nursing
programs in Canada, CNS interview participants felt their educational prepara-
tion for the role was too broad. Educators, CNS and administrator participants
also identified that lack of consistent and clearly defined CNS competencies and
shortages of faculty with CNS experience limited opportunities to promote role
understanding and role socialization and to develop skills for managing challenges
to role implementation. As these participants explained,
There is a lack of consistency amongst education programs for CNSs.
Generally speaking they dont have a clear sense of what should be
involved in CNS education. So you end up with very broad and multidi-
mensional characters who are out there carrying out what they think is
the role of the CNS, but everyone is doing it differently.
I dont necessarily know that faculty always understand the differences
between these [APN] roles. If all their education has been at the masters
level as administrators, educators or NPs, then how can they fully under-
stand the CNS role? They dont. So I think as educators we have to do a
better job at making certain what we teach our students and how to
operationalize their role.
Limited access to CNS-specific education may also contribute to role shortages in
areas with identified needs. A major barrier to recruitment of CNSs for First Nations
157
communities was the limited pool of nurses available to fill the positions (Health
Canada 2006; Veldhorst 2006). Key informants identified similar concerns about
health human resource planning and the need for recruitment efforts to ensure a
sufficient supply of CNSs to fill future roles. One CNS key informant explained,
Well, number one, the biggest barrier is they arent preparing them out of
university. This is a very specific role. The CNSs that are practising right
now, weve been around a long time, and a lot of retirements are occur-
ring right now. Theres no succession planning.
The CHSRF roundtable recommended that APN educational standards, require-
ments and processes across the country be standardized.
Discussion
It is possible that inconsistent use of CNS role titles and the use of differ-
ent terms to describe CNS practice in the literature contributed to the low
number of Canadian publications identified in our scoping review. However,
a recent international review of the CNS literature identified a similar
number of Canadian articles that accounted for only 4% of total publica-
tions (Lewandowski and Adamle 2009). This suggests that our scoping
review has been effective in capturing most Canadian publications. Factors
contributing to the low output of CNS-related research have not been
systematically identified. Possibilities include the lack of funding opportu-
nities and a limited supply of PhD-prepared CNSs and other investigators
interested in developing research programs in this area. Also, CNSs may be
more involved in research on clinical issues relevant to their specialty than in
health services research focused on their role (Bryant-Lukosius 2010).
Research will play a critical role in establishing the foundation for the
continued evolution of the CNS role. The PEPPA framework outlines a nine-
step participatory, evidence-based and patient-centred process that utilizes
research methods to determine the need for, define the role of, promote
implementation for, and evaluate the outcomes of APN roles (Bryant-
Lukosius and DiCenso 2004). The model can be applied to introduce new or
redesign existing CNS roles from a local practice setting, or regional, provin-
cial or national perspective and would be useful for developing a strategic
research plan. An important benefit of this framework for CNSs is the extent
of decision-maker and stakeholder involvement. This involvement has been
shown to facilitate the development of well-defined roles and promote stake-
holder understanding, acceptance and support for the APN role (Bakker et
al. 2010; McAiney et al. 2008; McNamara et al. 2009).
In applying the PEPPA framework, a key area for CNS research is to provide
a more accurate assessment of the current supply and demand for CNSs and
to monitor trends in CNS employment and integration within the health-
care system. The framework encourages needs-based health human resource
planning to provide rational data for decision-making about the introduc-
tion of APN roles and helps to maintain a focus on patient health needs and
avoid undue emphasis on the self-interest of APNs and other stakeholders
(Myers 1988). Role delineation studies that engage key stakeholders and
utilize consensus-based research strategies to determine CNS role priorities
and the competencies required to implement the role will be important for
achieving role clarity and role understanding and refining CNS curricula.
National roundtable participants who reviewed the DSS report also recom-
mended a similar approach for the future planning of CNS roles.
There is substantial international data about the effectiveness of CNS roles.
However, interview and national roundtable participants identified the
need for better evidence about the cost-effectiveness of these roles from a
Canadian context. Studies that assess CNS role outcomes and identify how
various components of the role contribute to these outcomes will be impor-
tant for ongoing role clarification. If decision-maker uncertainty about role
benefits persists, CNS roles will remain vulnerable to layoffs and potential
replacement by other providers. The shortfall of CNS-related research
in Canada is very striking. Strategies are required to increase capacity to
conduct CNS research and to develop an academic community of APN
faculty, researchers and CNSs in this field.
The role of advanced practice nurses in global and Canadian healthcare
systems has never been stronger. As clinical experts, leaders, and change
agents, APN roles are in high worldwide demand as a strategy for develop-
ing sustainable models of healthcare (Bryant-Lukosius et al. 2004; Schober
and Affara 2006). The same cannot be said about the CNS role in Canada.
Despite four decades of experience, growing international evidence about
their effectiveness, and recognition among some study participants about
the potential benefits of CNSs for patients, providers and the health system,
there is a lack of national vision about the role of the CNS in Canada. This
lack of vision corresponds with absent provincial or national policies or
investments to support CNS role development and integration.
159
While the evidence indicates that CNSs can positively impact the health of
Canadians and address important policy priorities related to patient access
to care, patient safety, quality of care, healthcare costs, evidence-based prac-
tice and improved nursing practice, they have no national voice or influen-
tial champions to communicate this information to key policy and health-
care decision-makers. The declining number of CNSs over the last decade
suggests that the future of CNSs in Canada is in jeopardy. Several factors
known to be important for the development of professional and advanced
nursing roles and for role legitimacy within the Canadian healthcare system
are limited or absent. They include the collective commitment of the nurs-
ing profession, ongoing development of the scientific basis for the role, and
access to relevant education and curricula to ensure role clarity and the
competency of CNS practitioners (Brown 1998; Bryant-Lukosius et al. 2004;
Registered Nurses Association of Ontario 2007). The sustainability of CNS
roles will depend on the extent to which CNSs, the nursing profession, APN
educators, regulatory agencies, healthcare funders and decision makers can
be galvanized to address these role barriers.
If the role is to survive over the next decade, CNSs will need to regain their
national voice and prominence as clinical leaders in the health system.
Stronger national leadership by CAAPN and its CNS Council to facilitate
networking and relationship building with key stakeholders and champions
will be important for gaining CNS access to policy tables. CNSs also need to
re-establish their own vision for their role. A good model for these activities
has occurred in the United States, where CNSs also experienced a declining
workforce. Over the past six years there has been an influx of CNS-related
publications and policy activities driven by the National Association of
CNSs (NACNS 2003, 2004). They encompass efforts to establish a national
vision (Goudreau et al. 2007), clarify credentialing and certification issues
(Goudreau and Smolenski 2008), establish an empirical base for CNS educa-
tion (Stahl et al. 2008), increase enrolment in CNS education programs
(NACNS 2004) and document the impact of the role on patient, provider
and health systems outcomes (Fulton and Baldwin 2004). There are also
numerous reports of recent innovations in CNS practice, including periop-
erative care (Glover et al. 2006), cardiovascular care (Aloe and Ryan 2008),
emergency care (Chan and Garbez 2006), rapid response teams (Polster
2008) and a shared care CNSMD model (Sanders 2008). In the United
States, Magnet status is a prestigious designation awarded to hospitals that
attract and retain highly qualified nurses and that have achieved excellence
in professional nursing practice. In a recent study of Magnet-status hospitals,
87% and 92% of administrators reported that CNSs were important for,
respectively, achieving and maintaining Magnet status (Walker et al. 2009).
CNSs will also need to do a better job of communicating their roles and
how they make a difference to key stakeholders. In contrast to the five inte-
grated sub-roles (clinician, educator, researcher, consultant and leader) that
define the CNS role in Canada (CNA 2009), CNSs in the United States are
described as having three spheres of influence: patients/populations, nurses/
nursing practice and organizations/health systems (NACNS 2004). A recent
international review of the CNS literature supports the spheres of practice
identified by the NACNS (2004) and confirms three areas of CNS practice:
managing the care of complex and vulnerable populations, educating and
supporting interdisciplinary staff, and facilitating change and innovation
within the health system (Lewandowski and Adamle 2009). Examining this
model and its relevance to the Canadian healthcare system may be a first step
in clarifying the CNS role and in particular coming to consensus about the
nature of the clinical aspects of the role. The CNA (2008) emphasizes the
clinical role of the CNS enacted through direct interactions with patients
or through supportive and/or consultative activities. Lack of clear direc-
tion about clinical role responsibilities that reflect advanced practice or
what constitutes supportive and consultative clinical activities has made this
aspect of CNS roles open to various interpretations.
The goal of regulation and title protection is the protection of the public.
The arguments put forth for CNS title protection have more to do with role
clarity and role preservation than public safety. We found few reports of CNS
involvement in expanded practice, and thus the need to expand CNS scope
of practice beyond that of the registered nurse with the associated regulatory
changes has not been established. Furthermore, we know from experience
with the integration of NP roles that significant policy changes such as title
protection occur slowly, with small incremental changes over many years
and only when the policy change is consistent with government agendas
(Hutchison et al. 2001). Thus energy focused on obtaining title protection
will be misspent and unsuccessful, given the lack of political support for this
policy among nursing regulators and government decision-makers. Finally,
title protection will not address the fundamental barriers to role integration,
namely the lack of CNS role clarity and the need for a national stakeholder
consensus about the role CNSs should play in the Canadian healthcare
system. These issues must be addressed first, before the need for title protec-
tion can be determined.
161
A more comprehensive examination of APN education programs and
the barriers to providing CNS-specific curricula is required. However, the
generic nature of some advanced practice programs or course offerings
suggests that compared to the CNA (2008), graduate programs may view
advanced practice more broadly as a level of practice relevant to a number of
nursing roles rather than relating to specific clinical roles such as the CNS or
NP that integrate education, leadership, research and consultative expertise.
National roundtable and interview participants were in agreement about the
need for improved consistency and national standards for CNS education.
Given that the last national review of CNS role competencies occurred in
1997, a pan-Canadian initiative to evaluate and update these competencies
and to provide the basis for educational review and curricula development
is warranted. Clear education standards and role competencies will provide
faculty and prospective students with a better understanding of the CNS role
and may facilitate recruitment to education programs with curricula that
offer a good match with CNS practice.
Conclusion
This decision support synthesis provides the most comprehensive examina-
tion of CNS roles in Canada to date. While the published data are limited,
the integration of data from key informant interviews and focus groups was
particularly useful in providing a current snapshot of this role. Important
issues and challenges confronting CNSs include the lack of empirical data to
support role development, the lack of national leadership and a clear vision
of the role, and the need for more relevant and consistent CNS education.
The consistency between study participant perceptions of these challenges
and those reported in the national and international literature lends strength
to our study findings.
CNSs have much to offer Canadian patients, health providers, organizations
and health systems. Full integration of the CNS role could address many key
policy issues confronting the healthcare system. These include improving
timely patient access to highly specialized and complex care, particularly for
vulnerable and high-risk populations; containing healthcare costs through
improved coordination of services and evidence-based care; and maximiz-
ing nursing health human resources through improved clinical support and
retention of nurses at the bedside. Achieving this potential and the long-term
sustainability of the CNS role in Canada will require intersectoral approaches
and the national commitment of CNSs and the nursing profession.
Acknowledgements
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167
The Role of Nursing Leadership
in Integrating Clinical Nurse
Specialists and Nurse Practitioners
in Healthcare Delivery in Canada
Junior Faculty, CHSRF/CIHR Chair Program in Advanced Practice Nursing (APN)
McMaster University
Hamilton, ON
Halifax, NS
St-Jrme, QC
Hamilton, ON
Toronto, ON
Hamilton, ON
Abstract
Supportive nursing leadership is important for the successful introduction and
implementation of advanced practice nursing roles in Canadian healthcare settings.
For this paper, we drew on pertinent sections of a scoping review of the litera-
ture and key informant interviews conducted for a decision support synthesis on
advanced practice nursing to describe and explore organizational leadership in
planning and implementing advanced practice nursing roles. Leadership strategies
that optimize successful role integration include initiating systematic planning to
develop the roles based on patient and community needs, engaging stakeholders,
using established Canadian role implementation toolkits, ensuring utilization of all
dimensions of the role, communicating clear messages to increase awareness about
the roles in the organization, creating networks and facilitating mentorship for those
in the role, and negotiating role expectations with physicians and other members of
the healthcare team. Leaders face challenges in creating and securing sustainable
funding for the roles and providing adequate infrastructure support.
Oakville, ON
Ivy Bourgeault, PhD
Ottawa, ON
Hamilton, ON
Introduction
Nursing leaders play a key role in shaping the nursing profession to be more
responsive to our changing healthcare system. In Canada, nursing leaders can be,
but are not limited to, chief executives; frontline, middle and senior managers;
administrators; professional practice leaders; leaders in regulatory bodies; govern-
ment officials; and policy makers. Important qualities of effective nursing leaders
include being an advocate for quality care, collaborator, articulate communica-
tor, mentor, risk taker, role model and visionary (Canadian Nurses Association
169 The Role of Nursing Leadership in Integrating Clinical Nurse Specialists and
Nurse Practitioners in Healthcare Delivery in Canada
[CNA] 2002). This is a challenging era for both nursing and healthcare because of
complex issues such as inadequate funding, health human resource shortages and
the increasing need for services for our aging population. Effective planning and
implementation of advanced practice nursing roles in healthcare settings have the
potential to help address these challenges.
Advanced practice nursing is an umbrella term for both clinical nurse specialist
(CNS) and nurse practitioner (NP) roles. CNSs are registered nurses (RNs) who
have a graduate degree in nursing and expertise in a clinical nursing specialty
(CNA 2009a). NPs are registered nurses with additional educational prepara-
tion and experience who possess and demonstrate the competencies to autono-
mously diagnose, order and interpret diagnostic tests, prescribe pharmaceuticals
and perform specific procedures within their legislated scope of practice (CNA
2009b: 1). Core advanced nursing practice dimensions include direct patient care,
research, leadership, consultation and collaboration (CNA 2008), but considerable
variability exists across advanced practice nursing roles in terms of time spent in
each activity. CNSs and NPs work in a variety of practice settings and have gained
some traction in the Canadian healthcare system since their first introduction in
the 1960s (Kaasalainen et al. 2010). However, many obstacles continue to impede
their full integration (DiCenso et al. 2010c).
The integration of advanced practice nurses (APNs) into healthcare systems has
relied heavily on nursing leaders at the national, provincial, regional and local
organizational levels. At the national level, nursing leaders in government and
professional associations have supported the integration of APNs in Canada in
a number of ways. Examples of this support include (1) the development of an
advanced nursing practice framework (CNA 2008) and position statements for
CNSs (CNA 2009a) and NPs (CNA 2009b) by the CNA, (2) the Canadian Nurse
Practitioner Initiative (CNPI) ( 2006b), (3) the formation of a national Canadian
Clinical Nurse Specialist Interest Group (CCNSIG) in 1989 (CCNSIG became
the Canadian Association of Advanced Practice Nurses [CAAPN] in 1997),
(4) the collaboration of the Canadian Nurses Protective Society with the Canadian
Medical Protective Association to address liability issues for NPs (Canadian
Medical Protective Association and Canadian Nurses Protective Society 2005),
(5) the conceptualization of innovative CNS roles in remote communities by First
Nations and Inuit Health of Health Canada, formerly known as the First Nations
and Inuit Health Branch (Veldhorst 2006), and (6) the funding of a decision
support synthesis on advanced practice nursing by the Office of Nursing Policy,
Health Canada and the Canadian Health Services Research Foundation (CHSRF)
(DiCenso 2010b). There are also many examples of nursing leadership at the
provincial/territorial and regional levels that support advanced practice nursing,
for example, the development and implementation of provincial and territorial
legislation authorizing the NP role. This paper will focus on the roles of nursing
leaders at the organizational level in facilitating the integration of CNSs and NPs
in healthcare settings.
Methods
This paper is based on a scoping review of the literature and qualitative inter-
views completed for a decision support synthesis that was conducted to develop
a better understanding of advanced practice nursing roles, their current use, and
the individual, organizational and health system factors that influence their effec-
tive development and integration in the Canadian healthcare system (DiCenso et
al. 2010b). The synthesis methods are described in detail in an earlier paper in this
issue (DiCenso et al. 2010d).
We conducted the scoping review using established methods (Anderson et al.
2008; Arksey and OMalley 2005) to map the literature on advanced practice
nursing role definitions, competencies and utilization in the Canadian healthcare
system; identify the policies influencing the development and integration of these
roles; and explore the gaps and opportunities for their improved deployment.
We conducted a comprehensive appraisal of published and grey literature ever
written about Canadian advanced practice nursing roles, as well as reviews of the
international literature from 2003 to 2008. In keeping with the tenets of scoping
reviews, we did not exclude articles based on methodological quality. To identify
the relevant literature, we searched Medline, CINAHL and EMBASE, performed
a citation search using the Web of Science database and 10 key papers, reviewed
the reference lists of all relevant papers, and searched websites of Canadian profes-
sional organizations and national, provincial and territorial governments. Teams
of researchers extracted data from relevant papers and analyzed the data using a
combination of descriptive tables, narrative syntheses and team discussions.
We conducted interviews (n = 62) in English or French with national and inter-
national key informants including NPs (n = 13), CNSs (n = 9), nurse adminis-
trators (n = 11), nursing regulators (n = 7), government policy makers (n = 6),
nurse educators (n = 5), physicians (n = 7) and healthcare team members (n = 4).
We also conducted four focus groups with a total of 19 participants. We used
purposeful sampling to identify participants with a wide range of perspectives.
All key informants were asked the same questions that addressed reasons for
introducing the role(s) in their organization, region or province, how they were
implemented, key factors facilitating and hampering their full integration, the
nature of their collaborative relationships, their impact, success stories, and inter-
viewees recommendations for fully integrating the role. When our synthesis was
completed, CHSRF convened a multidisciplinary roundtable to develop recom-
mendations for policy, practice and research.
For this paper, we integrated findings from the Canadian literature that described
the role of nursing leaders in facilitating the integration of APNs with interview
data from those who identified leadership issues, especially the 11 Canadian nurse
administrators. These administrators came from five provinces and worked in
academic teaching centres, regional health authorities, community care agencies and
a rehabilitation and continuing care centre. International literature has been used to
provide global context and for further discussion about key issues when relevant.
Results
We highlight the most frequently mentioned themes that emerged from the litera-
ture and that were identified by our interview participants specific to leadership.
We begin with a general description of the importance of organizational leader-
ship in supporting advanced practice nursing roles and then focus on the leader-
ship role specific to planning for and implementing these roles.
Importance of Leadership in Supporting Advanced Practice Nursing Roles
Many papers address the importance of nursing leadership in facilitating, enhanc-
ing and supporting the introduction and integration of advanced practice nursing
roles in organizations (DAmour et al. 2007; Hamilton et al. 1990; Lachance 2005;
MacDonald et al. 2005; Martin-Misener et al. 2008; Reay et al. 2003; Schreiber et
al. 2005a; Stolee et al. 2006). Senior nursing administrators play an important role
in linking APNs to organizational priorities to improve nursing practice (Bryant-
Lukosius et al. 2004).
Reay et al. (2003) interviewed NPs and their supervisors (a mix of frontline and
senior managers) in Alberta to identify leadership challenges for managers of NPs.
They identified challenges related to clarifying the reallocation of tasks, manag-
ing altered working relationships within the nursing team, and continuing to
manage the team as new issues emerged. Based on these results, Reay et al. (2003)
proposed eight leadership strategies for managers introducing NP roles. These
strategies include (1) encouraging all team members to sort out who does what,
(2) ensuring that task reallocation preserves job motivating properties, (3) giving
consideration to how tasks have been allocated when issues identified as personal
conflict arise, (4) paying attention to all perspectives of the working relationships
within the team, (5) facilitating positive relationships between team members,
(6) leading from a balcony perspective, (7) working with the team to develop
goals that are not overly focused on the NP and (8) regularly sharing with other
managers the experiences and lessons learned in introducing NPs. These strategies
place an emphasis on working with the team and managing working relationships
among all team members rather than focusing solely on individual NP roles.
Consistent with this literature, the administrators we interviewed recognized the
importance of their role in providing support to APNs and enabling the integra-
tion of advanced practice nursing roles in their work settings, as the following
quotes illustrate:
In my experience, the best way to help APNs to grow and to move their
role forward is to continually be in partnership with them to plan whats
going to happen next and to not let yourself get so busy that youre just
going to let them go because theyre obviously fine.
I think the number one key factor is having the administrative support,
and by administrative support I mean administrative leadership in the
organization to help introduce, shape and help the role evolve. And I
think that really is the number one in a hospital setting. I think in the
community we have a gap in terms of nursing leadership being available
in the PHCNP settings where they work.
As more organizations have moved to program management, many CNSs and NPs
report to supervisors who are not nurses but are from other health or business
backgrounds; some NPs also report to medical directors or other physicians. While
there is limited research about the most effective models of advanced practice nurs-
ing role supervision, reporting to a senior nurse administrator may be important
for negotiating the continued implementation of the role, addressing nursing
practicerelated role barriers, role socialization and supporting the development
of a nursing orientation to practice (Bryant-Lukosius et al. 2004). Participants
commented on the important role administrators can have in ensuring that differ-
ent reporting relationships for APNs are clear, as this administrator did:
So an administrator does well when they can work at reducing that feel-
ing of isolation for them [APNs] and having lots and lots of infrastruc-
ture support and having a very clear reporting relationship. What does it
mean to have a dual reporting relationship? Most APNs have one. It is the
responsibility of those two, to whom they report, to figure out what does
that look like and what can they expect from us as a team. So those are
really important.
Nursing administrative leadership is critical to help streamline the advanced prac-
tice nursing integration process and to work with APNs to smooth the way for
day-to-day practice.
Systematic Planning for Advanced Practice Nursing Roles
Responsibilities for planning for and hiring APNs are usually those of the nurs-
ing administrator. The importance of undertaking a systematic process to assess
patient or community needs, develop the advanced practice nursing role to
address those needs, and introduce, implement, and evaluate the role was empha-
sized both in the literature (Bryant-Lukosius et al. 2004, 2007; Dunn and Nicklin
1995; Mitchell et al. 1995) and interviews. Many of our participants highlighted
how poor planning for CNS and NP role implementation under tight time pres-
sures, sometimes in response to funding availability, was a barrier to the successful
integration of the roles. Furthermore, as the following quote from an administra-
tor illustrates, participants reported that it was a crucial determinant of successful
role integration to first identify the service need or practice gap and, based on that
assessment, then select the most suitable role for the position.
It is important to choose the appropriate NP role. And thats based on
the population need, the fit among the individual NP, the position, other
stakeholders and in some cases, the community.
Developing guidelines, expectations and priorities for the CNS or NP position and
creating a supportive environment facilitate role implementation and integration
(Bryant-Lukosius et al. 2004; CNPI 2005; Chaytor Educational Services 1994).
Cummings and McLennan (2005) discuss the importance of individualizing
advanced practice nursing positions to ensure there is a good fit between the CNS
or NP role requirements and the individual filling the role. Participants suggested
that CNS and NP roles need to be dynamic and continuously negotiated based on
the needs of patients, organizations and the healthcare system, and on the skill set
of the individual CNS or NP. As the following quote shows, NP and CNS partici-
pants agreed a role negotiation process was desirable:
I wish there was some way when a new role was introduced that you could
truly negotiate and work that out with the program that you are work-
ing with because I think its at that level that things happen, in terms of
the full integration of the role. There certainly has to be recognition and
acceptance at the administration level.
Adopting Toolkits
Various participants highlighted the importance of utilizing existing advanced
practice nursing implementation toolkits (Advanced Practice Nursing Steering
Committee, Winnipeg Regional Health Authority 2005; Avery et al. 2006; CNPI
2006a) to facilitate CNS and NP role implementation. The Participatory, Evidence-
based, Patient-focused Process for Advanced practice nursing role development,
implementation and evaluation (PEPPA) framework as described by Bryant-
Lukosius and DiCenso (2004) is a systematic healthcare planning guide used to
minimize or prevent commonly known barriers to the effective development,
implementation and evaluation of advanced practice nursing roles. A number of
participants from different provinces commented on how their use of the PEPPA
framework gave them a structured, systematic, thorough and organized role imple-
mentation plan, as demonstrated by a quote from a nursing administrator.
Weve taken a very structured approach to the introduction of the role.
We took the PEPPA framework right from the beginning, and we used
the framework to build our call for applications for funding for a nurse
practitioner. We shared the research. We shared the information about
what are the common barriers and common facilitators to the role. Right
from the beginning weve asked communities or teams or directors or
physicians or whoever it might be to answer some of those key questions.
Whats your current model of care, whats your current population, where
are the gaps and what are the needs? And based on those gaps and those
needs and what your current model of care looks like, we can then have a
conversation with them about, well, is it really a nurse practitioner thats
going to meet those needs, or in fact, has [their] going through that exer-
cise identified that what they need is some pharmacy resources, or maybe
they need some social worker resources. I think using the PEPPA frame-
work right from the start has been of tremendous value. Weve had a very
organized approach to it. Weve managed the introduction carefully.
It is with reference to the PEPPA framework where we see the clear overlap between
the insights garnered from literature and from the key informant interviews.
Engaging Stakeholders
An important consideration when planning for new health practitioner roles
is the engagement of key stakeholders within and outside of the organization.
MacDonald et al. (2005, 2006) and Schreiber et al. (2005a, 2005b), in their stud-
ies on the introduction of advanced practice nursing roles in British Columbia,
identified the importance of engaging nursing leaders from healthcare settings,
government, professional organizations and education in systematically planning
for role introduction and implementation.
Stakeholder participation at the onset of CNS and/or NP role development and
introduction is critical for ensuring support for the planned change, even if it
lengthens the planning process (Cummings and McLennan 2005; MacDonald et
al. 2006; Martin-Misener et al. 2009). Participants emphasized the importance
of the early involvement of key stakeholders such as physicians, staff nurses and
other healthcare providers in planning and implementing NP and CNS roles.
Some administrators developed working groups of stakeholders to plan for CNS
and NP roles. Most participants reported that the extra time, energy and resources
needed to ensure stakeholder participation was worth the effort. In the words of
one administrator participant:
We really did stop, consulted with key stakeholders, met with our physi-
cian colleagues, looked at the populations we are serving and then iden-
tified where we thought we had the best opportunity for capacity and
readiness to integrate the roles.
Administrators noted that a lack of stakeholder involvement contributed to poor
role clarity. Many described the effect that successful advanced practice nurs-
ing integration had on an organizations willingness to integrate more APNs, as
described by the two administrators below.
Getting more into the same programs is not an issue because they [APNs]
are well received.
The organization has already proven very successful with an APN in
another area, so I get people knocking on my door, saying, how do I get
one of those?
There was a sense from participants that strategies to enlist stakeholders have had
good results in gaining their support and in addressing their concerns.
Implementing the Advanced Practice Nursing Role in Healthcare Settings
Nursing leaders have many responsibilities related to the implementation of
advanced practice nursing roles. Reay et al. (2003, 2006) developed a concep-
tual model based on their longitudinal study of the introduction of a new NP
role into Albertas healthcare system. The central theme of the model was titled
Recognizing and Celebrating Small Wins, in which managers, based on their
experience working with the inter-professional team, acknowledged that their
best chance for success was through small steps that moved them toward the larger
goal of gaining acceptance for the role (Reay et al. 2006: 993).
Our results suggest the most significant responsibilities of nursing leaders imple-
menting advanced practice nursing roles include finding and sustaining funding,
providing adequate infrastructure and resources, ensuring utilization of all role
dimensions, creating awareness of the roles, and enabling network support and
mentorship. Each is described below.
Finding and Sustaining Funding
Nursing leaders often have the responsibility to find funding for advanced practice
nursing roles. Administrators working in acute care organizations reported being
forced to choose between funding an advanced practice nursing position or other
registered nurse services, as this administrator explains:
The mistake we made is that when the ministry told us that we had to
find those NP salaries within nursing, we did a disservice in the sense
that nursing said, Okay fine. Well figure it out somehow Well find
it somehow rather than saying, No, this is not acceptable; if we want
this, it cant be a staff nurse or NP. Someone has to find the money. Now
six years later and we cant find the money, and the comeback has been,
Youve always been successful, and Dig a little harder and Im sure
youll find it.
Some participants, as exemplified in the following quote from an administrator,
commented on the interplay between financial support required for the role and
the support needed from many sources to substantiate the importance of the role
and associated funding requirements.
When youre looking at the integration of the CNS and the NP, there
needs to be support from a government level in terms of funding. There
needs to be support from an administrative level in terms of support for
the development of new roles and responsibilities and the implementa-
tion, and that implementation needs to involve support and evaluation.
There needs to be support from other healthcare professionals, particu-
larly physicians in terms of the collaboration. That support is critical
because if you dont get that support then your ability to implement needs
a lot more tenacity in order to make it work, to make it successful. When
youve got the support and funding, then you have the opportunity to
show what you can do.
The multidisciplinary roundtable convened by CHSRF to formulate evidence-
informed policy and practice recommendations based on the synthesis findings
recommended that advanced practice nursing positions and funding support
should be protected. Funding protection should follow implementation and
demonstration initiatives to ensure stability and sustainability for these roles (and
the potential for longer-term evaluation) once they have been incorporated into
the healthcare delivery organization/structure (DiCenso et al. 2010b).
Providing Adequate Infrastructure and Resources
Inadequate resources to support the CNS and NP roles (e.g., support staff, physi-
cal space, technology and infrastructure) is a frequently reported concern (Allard
and Durand 2006; CNA 2008; DAmour et al. 2007; Lachance 2005; MacDonald et
al. 2005; Martin-Misener et al. 2008; Turris et al. 2005; Worster et al. 2005). Most
administrator participants commented on the insufficient infrastructure resources,
as the following two quotes from an administrator and an APN demonstrate.
Its a slow and steady approach to implementation. We need to keep
thinking about it and have those infrastructures in place to make sure we
are setting them up for success and not setting them up to fail.
The system needs to be prepared to support them [CNSs] in that you
need an office; you need a phone; you need a pager. Ive seen CNSs hired
and then it comes time for them to fill out an annual report and they
dont have a file folder to put it in. You know you need space. It is very
hard to put six CNSs in an office the size of a closet and think they can
work there.
Inattention to basic resources such as office space, clerical support, commu-
nication and technology marginalizes the purpose and legitimacy of CNS and
NP roles. Participants also noted a lack of supportive policies that would allow
APNs to function to their full scope. Cummings and McLennan (2005) suggest
that nursing leaders in healthcare settings can influence policy change and shape
the healthcare system by facilitating changes in the workplace that continually
improve quality of care and meet fiscal realities.
Ensuring Utilization of Role Dimensions
CNSs and NPs value the non-clinical aspects of their role, and these activities
contribute to role satisfaction (Bryant Lukosius et al. 2004; Sidani et al. 2000).
However, insufficient administrative support and competing time demands asso-
ciated with clinical practice are frequently reported barriers to participating in
education, research and leadership activities (Bryant-Lukosius et al. 2004; Hurlock-
Chorostecki et al. 2008; Irvine et al. 2000; Pauly et al. 2004; Sidani et al. 2000). This
is particularly problematic for NPs in acute care, who usually report to both a nurs-
ing and a medical director. In our interviews, we learned that physicians wanted
the NPs time devoted mainly or exclusively to clinical practice, whereas nursing
administrators wanted the NPs to also have some protected time to engage in lead-
ership, research and education activities. A nursing administrator stated:
They are delivering excellence in clinical care, personally working well
with the team, with other interdisciplinary team members as well, but
they have not been making as strong a contribution to the science of nurs-
ing, or to the development of the practice of nursing and certainly not to
the development of the system.
Role expectations can be enhanced and negotiated by strong leadership from
healthcare managers who can communicate a clear vision for the multiple dimen-
sions of the role to team members and support the role within the organization
(Reay et al. 2003, 2006; van Soeren and Micevski 2001). The development of
detailed written job descriptions (Cummings et al. 2003) and ongoing discussions
between managers and team members promote a greater understanding of the
role (Wall 2006).
As shown in the following quote from an APN, a key strategy to protect the vari-
ous dimensions of the role is administrative support.
Structuring the role [is needed] so that theyre actually successful in
allowing individuals the time to do the research, to do the education, to
go to the conferences, to do the learning that needs to be done so that they
can come back and mentor other individuals. Its not just about seeing a
hundred patients in a month.
Actively shaping roles allows fulfillment of advanced practice nursing role dimen-
sions in addition to patient care, and this in turn contributes to successful integra-
tion as well as advancement of the nursing profession.
Creating Awareness of Advanced Practice Nursing Roles
Nursing leaders raised concern about the lack of awareness of advanced practice
nursing roles within healthcare organizations. Administrators reported regularly
articulating information about advanced practice nursing to physicians, health-
care team members and other administrators to increase awareness. Inadequate
healthcare team awareness of the CNS and NP roles has been identified as a
barrier to advanced practice nursing role integration (for example, Bailey et
al. 2006; CNPI 2006a, 2006b; Hass 2006; Urquhart et al. 2004). Among the six
government interview participants in our scoping review, lack of awareness
among healthcare team members and the public was the most commonly identi-
fied barrier to successful advanced practice nursing role integration (DiCenso et
al. 2010c), and many felt it was the role of national and provincial/territorial nurs-
ing leaders to increase awareness, as shown in the following quote:
It needs to come from the professional nursing associations. Those that
represent nurses need to create a conscious awareness in the system of the
[CNS and NP] roles. There needs to be the consistent and constant infor-
mation, resources and tools that employers can access to understand how
they can integrate these nurses into the system to improve their efficiency
and quality. There is a need for ongoing research, definitely because the
environment is constantly changing and we are seeing advanced practice
nurses that are practising in different settings, doing different sorts of care
and treatment and therapies.
The roundtable recommended that a communication strategy be developed (via
collaboration with government, employers, educators, regulatory colleges and
professional associations) to educate nurses, other healthcare professionals, the
Canadian public and healthcare employers about the roles, responsibilities and
positive contributions of advanced practice nursing (DiCenso et al. 2010b).
Enabling Network Support and Mentorship
Administrators working in healthcare settings can play an important role in
advanced practice nursing integration by providing opportunities for network
support and mentorship. Co-location of APNs is a suggestion in the literature to
prevent CNSs and NPs from becoming isolated (Hamilton et al. 1990; Humbert et
al. 2007). A number of papers emphasize the importance of mentorship, especially
for those in their first CNS or NP role (Lachance 2005; Reay et al. 2003, 2006; van
Soeren et al. 2007). The importance of networking support systems (Micevski et
al. 2004; Roots and MacDonald 2008) and enhanced professional development
opportunities was noted (CNA 2008). Participants echoed the value of these
strategies to support advanced practice nursing roles and suggested a number of
networking support systems. These included the establishment of NP or NP and
CNS joint committees or special interest groups to assist with ongoing planning
for advanced practice nursing roles and to share and address common issues. This
could also assist with the development of a community of practice model to foster
professional development. In the following quote, an administrator describes her
role in facilitating an opportunity for networking:
I facilitated an NP community of practice, recognizing that we were
going to be hiring really novice NPs, even though they were experienced
registered nurses, and putting them into a brand new role in sometimes
distant communities, where there were no NP mentors in the system and
not many NPs anymore in the province. What we did is structure our
community of practice to say that, okay, were going to come together
regularly in face-to-face meetings as well as connecting electronically
to support one another as they try to pioneer this new role. When Ive
surveyed the community over the last couple of years, theyve [NPs] said
theres no question that having that support network, that support struc-
ture, was critical to that first integration of their role.
Leaders can play an important role in organizing supportive networks and coor-
dinating mentorship opportunities for CNSs and NPs helping to integrate these
roles into their organizations.
Discussion
The purpose of this paper was to describe and explore the roles of nursing
leaders at the organizational level in facilitating the integration of CNSs and
NPs in healthcare settings. The issues facing nursing leaders responsible for
integrating CNS and NP roles are complex and require multiple strategies
for the variety of sectors in which APNs work.
Our synthesis (DiCenso et al. 2010b) provided an important opportunity
to combine relevant literature and qualitative interview data to understand
the role of nursing leaders particularly at the organizational level - in the
integration of CNS and NP roles in Canada. The 11 nursing leaders worked
in various sectors including acute care, rehabilitation, community care and
regional health authorities. There was remarkable consistency in leadership
issues identified by the interview participants and the relevant literature.
A strength of our study is that the nurse leaders we interviewed were
informed about advanced practice nursing, had experience in planning and
implementing advanced practice nursing roles and understood the impor-
tance of the nursing leadership role. However, it is not clear if this is true of
all nurse administrators. Further exploration of the information needs of
nursing leaders and other team members about advanced practice nursing
roles is required. A limitation of our study was that we did not interview
administrators of small community hospitals, long-term care facilities, or
primary healthcare settings such as community health centres or family
health teams. They may have had different perspectives, and this is an area
for future research.
Nursing leaders have multiple responsibilities and play a key role in the inte-
gration of APNs in healthcare settings. Their role in the integration of CNSs
and NPs is not an event but a continuous process, characterized by regular
communication, negotiation, and management of people and processes.
Successful leadership strategies for integrating APNs in healthcare organiza-
tions that were identified through the interviews and literature included
(1) using established Canadian implementation toolkits (Advanced Practice
Nursing Steering Committee, Winnipeg Regional Health Authority 2005;
Avery et al. 2006; CNPI 2006a) and frameworks such as the PEPPA frame-
work (Bryant-Lukosius and DiCenso 2004) to carefully plan and structure role
introduction, (2) engaging stakeholders, (3) communicating clear messages to
increase awareness of CNS and/or NP roles in their organization, (4) provid-
ing leadership to support individuals and create networks, and (5) negotiating
role expectations with physicians and other members of the healthcare team.
Introducing and implementing CNSs and NPs into healthcare settings is not
without its challenges. One of the biggest problems facing nursing leaders
is creating and securing sustainable funding for the roles and the provision
of resources. Finding a resolution to this problem is critical, because the
changing demographics of the Canadian population and the increased inci-
dence and prevalence of chronic diseases will create more opportunities for
CNS and NP roles. Innovative models of interdisciplinary care that include
NPs have increased patient access to care in different regions of the coun-
try (DiCenso et al. 2010a). Both CNS and NP roles are expanding into new
practice sites such as long-term care, and future studies are needed to better
understand their role implementation in these settings (Donald et al. 2009).
The development and implementation of advanced practice nursing roles
is influenced by economic conditions and health human resources issues.
Current budgetary crises threaten administrators ability to sustain fund-
ing for APNs and to create new, innovative CNS and NP roles. This cyclical
economic influence on advanced practice nursing roles not only threatens
a relatively small pool of highly trained practitioners, but also negatively
impacts recruitment of future APNs. Nurse administrators need the support
of professional organizations and regulatory bodies to influence healthcare
policy and to lobby for sustained funding. Health human resource planning
is needed to break the all too familiar cycle of not having enough quali-
fied individuals to fill vacant CNS and NP roles, and then having waves of
organizational layoffs that result in insufficient employment opportunities.
Clearly, we need to create a more consistent and sustainable approach to
funding APN roles to make them less vulnerable to the economic ebbs and
flows of our healthcare system.
An awareness of the value and effectiveness of NP and CNS roles will support
the development of positive CNS and NP policy. Nurse administrators can
play an important role in increasing awareness of successful NP and CNS
roles in their organizations. Professional organizations, regulatory bodies and
researchers can reinforce and contribute to a nationwide awareness of the
positive benefits of CNSs and NPs for patient care and the healthcare system.
In conclusion, nursing leaders are vital to the integration of CNSs and NPs
into the Canadian healthcare system. This paper draws attention to the vari-
ous roles nursing leaders in organizations are playing as they plan, imple-
ment and support this process. Future research is needed to distinguish the
roles leaders in organizations, professional associations, regulatory bodies
and government can play and specific strategies they can use to successfully
integrate NP and CNS roles in Canada.
Acknowledgements
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186
COMMENTARY
Nursing leaders play a critical role in creating and enacting a vision for collabora-
tive practice with advanced practice nurses (APNs). In this special issue, Nancy
Carter and colleagues have identified many important influences and outcomes of
successful nursing leadership in the context of promoting advanced practice nurs-
ing roles. The authors make a strong case for the importance of nursing leadership
to facilitate large-scale systems change, noting the multiple levels on which nurs-
ing leaders work to ensure advanced practice nursing roles are well introduced to
improve patient care. Nursing leadership can move an innovation like advanced
practice nursing practice forward toward the tipping point, when the new idea
takes hold and becomes socially acceptable and desired, when the early adopters
have influenced the early majority and about 15 to 20% of the population have
adopted the idea (Berwick 2003). In many ways our nursing leaders have achieved
this with advanced practice nursing roles, and we should celebrate. APNs are now
more common, and certainly members of the public are proud to speak of the
roles APNs play in their health services. An idea that once captured the minds of a
select few has spread, thanks in large part to the nursing leaders who had a vision,
believed in an idea, fought for it and worked to embed the change in the system.
Despite these early successes, awareness of advanced practice nursing roles among
nursing leaders varies considerably. Yet widespread awareness is essential if we
are to advance advanced practice nursing roles and realize the benefits of their
potential. All 11 nursing leaders that Carter and colleagues interviewed for their
study were well informed about advanced practice nursing roles and had practical
experience in planning and implemented them. However, many nurses in leader-
ship positions do not know what an APN is. How can this be? Are we educating
ourselves and our future leaders sufficiently to find creative solutions to care
Close to the Tipping Point
Pam Hubley, RN, MSc
Associate Chief, Nursing Practice, The Hospital for Sick Children
Toronto, ON
187 Close to the Tipping Point
delivery challenges? The authors recognize that further investigation of nursing
leaders information needs is required, particularly in small community hospitals,
primary healthcare settings and long-term care facilities.
Carter and colleagues found many papers in their study that recognized the
essential role of nursing leaders in facilitating and supporting the introduction
of advanced practice roles into their organizations. Strategies are proposed in the
literature for successfully introducing an advanced practice nursing role. No one
would doubt the importance of meticulous planning, however, it is not the only
way to introduce an advanced practice nursing role into the health system. In my
experience, effectively supporting the advancement of advanced practice nursing
roles has sometimes been deliberate, while at other times a product of synchro-
nistic events the consequence of stars aligning, some would say. While logical,
systematic leadership is essential, advancing advanced practice nursing roles in a
system that is slow to change sometimes happens when the right leaders, the right
APN, the patient population, the right funding mechanism and the right timing
come together, rather than when all is carefully planned.
Participants in Carter et al.s study stressed the importance of using specifically
designed toolkits to implement advanced practice roles. While successful lead-
ers plan and carefully use systematic approaches like the PEPPA framework, they
must also seek opportunities to align linear planning with creative and reflective
processes. Paying attention to the idea of emerging futures connects practical
planning with creative thinking and possibilities. One of the crucial elements to
leadership I have learned is that leaders succeed when they see an emerging future
and generate enthusiasm for its possibilities. Seeing that emerging future involves
more than painting a picture of your vision; one must also use contextual cues
to help catapult ideas and innovations, and know when to act and when to wait.
In the context of advanced practice nursing, for example, when a team is talking
about the complexities of patient care and their dissatisfaction with gaps in the
system, an astute leader might facilitate a conversation about how things could be
different, pulling out ideas about the potential contribution an APN could make,
without directly or forcefully suggesting an advanced practice nursing role as the
solution. This kind of leadership seizes the moment and draws on local intel-
ligence and creativity, recognizing that timing is key and that change is dynamic
and organic.
The future of advanced practice nursing integration into the healthcare system
will require continued attention and collaboration across sectors. We need nursing
leaders from practice settings, education, regulatory, health policy and govern-
ment organizations deliberately working together to further shift systems of care
delivery. We need researchers to examine best practices, answer questions about
outcomes and their impact and generate new knowledge that APNs can apply
in their practice. We need leaders in nursing administration to advocate for new
ways of delivering care and focus efforts toward quality, safety and the creation of
healthy and healing environments where diverse professionals offer value-added
services. Our regulators and government agencies need to advocate for legislative
frameworks that make sense and allow APNs to practise without barriers, with-
out needing to create workarounds that waste time and money. We need more
education programs for APNs and educators to teach nurses who are interested in
becoming leaders how to advocate for advanced practice nursing roles and effect
systems change. We need to teach them how to create supportive infrastructures
and be effective nursing leaders, able to articulate business cases that advance
collaborative models and engage physicians and other health providers in partner-
ship and teamwork.
Ultimately, individual APNs who have been trailblazers have pushed the bounda-
ries to create new partnerships and new ways of delivering patient care. Their
success has been possible with support from nursing practice and academic lead-
ers, creating infrastructures to sustain roles and education for building capacity
in advanced practice nursing. In turn, scholarship has gathered the evidence to
substantiate the impact that advanced practice nursing roles have made on the
system and on patient care. The truth is, we all need each other, working together
to shift the system to where there is no question about why an advanced practice
nursing role would be useful and what an advanced practice nursing role could
contribute. We have early adopters and we have influenced the early majority. Now
we are close to the tipping point where we continue to spread the innovation of
advanced practice nursing and collaborative models of care. Working in partner-
ship, I am sure we will rise to this next leadership challenge!
References
Berwick, D.M. 2003. Disseminating Innovations in Health Care. Journal of the American Medical
Association 289 (15): 196975.
189
Clinical Nurse Specialists and
Nurse Practitioners: Title Confusion
and Lack of Role Clarity
Toronto, ON
Hamilton, ON
Halifax, NS
Hamilton, ON
St-Jrme, QC
McMaster University
Hamilton, ON
Oakville, ON
Introduction
Confusion about role titles and lack of role clarity pose barriers to the integration
of advanced practice nursing roles in the Canadian healthcare system. At a confer-
ence held by the Canadian Association of Advanced Practice Nurses in 2007, both
barriers were identified as pressing issues influencing the future development of
these roles. In Canada, clinical nurse specialists (CNSs) and nurse practitioners
(NPs) are recognized as advanced practice nurses. In some countries, such as the
Abstract
Title confusion and lack of role clarity pose barriers to the integration of advanced
practice nursing roles (i.e., clinical nurse specialist [CNS] and nurse practitioner
[NP]). Lack of awareness and understanding about NP and CNS roles among the
healthcare team and the public contributes to ambiguous role expectations, confu-
sion about NP and CNS scopes of practice and turf protection. This paper draws
on the results of a scoping review of the literature and qualitative key inform-
ant interviews conducted for a decision support synthesis commissioned by the
Canadian Health Services Research Foundation and the Office of Nursing Policy
in Health Canada. The goal of this synthesis was to develop a better understand-
ing of advanced practice nursing roles and the factors that influence their effective
development and integration in the Canadian healthcare system. Specific recom-
mendations from interview participants and the literature to enhance title and role
clarity included the use of consistent titles for NP and CNS roles; the creation of a
vision statement to articulate the role of CNSs and NPs across settings; the use of
a systematic planning process to guide role development and implementation; the
development of a communication strategy to educate healthcare professionals, the
public and employers about the roles; attention to inter-professional team dynamics
when introducing these new roles; and addressing inter-professionalism in all health
professional education program curricula.
Ivy Bourgeault, PhD
Ottawa, ON
Hamilton, ON
191 Clinical Nurse Specialists and Nurse Practitioners: Title Confusion and Lack of Role Clarity
United States, nurse anesthetists and nurse midwives are also advanced practice
nurses; however, in Canada, the nurse anesthetist role is just beginning to be
introduced and midwives are not required to be nurses. The Canadian Nurses
Association (CNA) defines advanced nursing practice as:
an umbrella term describing an advanced level of clinical nursing prac-
tice that maximizes the use of graduate educational preparation, in-depth
nursing knowledge and expertise in meeting the health needs of individu-
als, families, groups, communities and populations. It involves analyzing
and synthesizing knowledge; understanding, interpreting and applying
nursing theory and research; and developing and advancing nursing
knowledge and the profession as a whole (CNA 2008: 10).
Core advanced nursing practice competencies include direct patient care, research,
leadership, consultation and collaboration (CNA 2008). The extent of involve-
ment in each of these activities varies depending on the specific nature of the NP
and CNS roles.
Titles and activities typically delineate roles within the healthcare system.
However, there is confusion about advanced practice nursing titles, a lack of clar-
ity about the roles and role overlap (Griffiths 2006). For our purposes, the term
title confusion implies that CNS and NP role titles can be difficult to understand
and that one role title may be mistaken for the other, whereas lack of role clarity
indicates that NP and CNS roles are poorly differentiated and lacking in clearly
defined role activities. In this paper, we provide an overview of CNS and NP role
definitions and characteristics, explicate the title confusion and role clarity issues,
and describe their effect on healthcare team and public awareness and accept-
ance of the roles. We also summarize recommendations that have been made to
enhance title and role clarity so that the roles can be better integrated into the
Canadian healthcare system.
Methods
This paper is based on a scoping review of the literature and qualitative inter-
views completed for a decision support synthesis that was conducted to develop
a better understanding of advanced practice nursing roles, their current use, and
the individual, organizational and health system factors that influence their effec-
tive development and integration in the Canadian healthcare system (DiCenso et
al. 2010a). The synthesis methods are described in detail in an earlier paper in this
issue (DiCenso et al. 2010b). Briefly, we conducted a comprehensive examination
of all published and grey literature ever written about Canadian advanced practice
nursing roles and reviews of the international literature from 2003 to 2008. The
overall search yielded a total 2,397 papers, of which 468 were included in the scop-
ing review. Interviews (n = 62) and focus groups (n = 4 with a total of 19 partici-
pants) were conducted in English or French with national and international key
informants including CNSs, NPs, physicians, healthcare team members, educators,
healthcare administrators, nursing regulators and government policy makers.
When our synthesis was completed, the Canadian Health Services Research
Foundation (CHSRF) convened a multidisciplinary roundtable to develop recom-
mendations for policy, practice and research. For this paper, we focused on the
concepts of title confusion and lack of role clarity as described in the literature
and by our interview and focus group participants. Data from the literature, inter-
views and roundtable were then synthesized to form the basis for recommenda-
tions to reduce title confusion and enhance role clarity.
Results
Role Definitions and Characteristics
In Canada, NPs are registered nurses with additional educational preparation and
experience who possess and demonstrate the competencies to autonomously diag-
nose, order and interpret diagnostic tests, prescribe pharmaceuticals and perform
specific procedures within their legislated scope of practice (CNA 2009b: 1).
During the early years of NP registration, regulators used various titles to describe
NPs, such as registered nurses providing extended services in Alberta (Canadian
Institute for Health Information [CIHI] 2010: 37) and registered nurse, extended
class or RN(EC) in Ontario (College of Nurses of Ontario 2007). Titling of
NP roles is in transition; for the purposes of this paper we refer to NPs who are
registered as family/all-ages or primary care NPs as primary healthcare NPs
(PHCNPs), and to those who are registered as adult, pediatrics or neonatal NPs as
acute care NPs (ACNPs).
Work settings and the primary focus of NP practice vary. For instance, PHCNPs
typically work in the community in settings such as community health centres,
family physician offices, primary care networks and long-term care (CIHI 2008).
The PHCNPs main focus is health promotion, preventive care, diagnosis and
treatment of acute common illnesses and injuries, and monitoring and manage-
ment of stable chronic diseases. ACNPs typically provide advanced nursing care
across the continuum of acute care services for patients who are acutely, critically
or chronically ill with complex conditions; they work in settings such as oncology,
neonatology and cardiology (Kilpatrick et al. 2010). The amount of consultation,
education, research and leadership activities that NPs do varies depending on the
needs of patients and the setting. Education programs exist across Canada specifi-
cally to prepare nurses for the PHCNP and ACNP roles, the majority of which
are at the masters of nursing degree level (College and Association of Registered
Nurses of Alberta n.d.; Martin-Misener et al. 2010).
The title CNS refers to registered nurses (RNs) who have a graduate degree in
nursing and expertise in a clinical nursing specialty (CNA 2009a). The primary
responsibilities of the CNS depend on the particular needs of the setting and
include varying amounts of clinical practice, consultation, education, research
and leadership activities. CNSs mentor nurses, contribute to the development of
nursing knowledge and evidence-based practice, and address complex healthcare
issues for patients, families, other disciplines, administrators and policy makers.
They are leaders in the development of nursing and inter-professional policies
and practice guidelines. Specialty practice areas for CNSs are usually defined by a
population, setting, disease or medical subspecialty, type of care or type of prob-
lem. To the best of our knowledge, Canada does not currently have a specifically
titled CNS graduate education program, and only one program offers specifically
titled CNS courses (Martin-Misener et al. 2010). Education for CNSs typically
occurs through generic graduate education programs that complement clinical
expertise with broad-based knowledge and skills that can be applied to advanced
nursing practice. A healthcare administrator participant captured the confusion
regarding CNS education and credentials:
I think we need education that is a standard level of education. So to be a
CNS, you must have x, y and z, and then you will get a certificate or some-
thing that you can put on your wall that says I am a CNS. The NP exam,
you know, theyre regulated. Clearly theres an exam. There wasnt for a
while, but now there is for the Acute Care NPs and the specialties. I think
it adds credence to the role; it really does. And so from the policy perspec-
tive, at the government tables, people know what the NP does. I dont
think they even know that the CNS exists.
Understanding the differences between CNS and NP roles is challenging because
they share common role competencies (CNA 2008; Canadian Association of
Nurses in Oncology 2001). Figure 1 (Bryant-Lukosius 2004 and 2008) illus-
trates the differences between CNS and NP roles. At one end of the continuum,
CNSs spend proportionately more of their work time on professional develop-
ment, organizational leadership, research and education activities and may have
fewer responsibilities related to direct clinical practice. At the opposite end of
the continuum, NPs spend more of their work time providing direct patient
care compared to other role activities. Another important difference relates to
scope of practice. CNSs are authorized to perform the same controlled acts as an
RN. However, NPs have expanded clinical functions and legislated authority to
perform additional activities (i.e., diagnose, order tests and prescribe medication)
traditionally performed by physicians.
Figure 1.
Continuum of advanced practice nursing roles
Continuum of APN Roles
CNS NP
Integrated Role Domains
Professional development
Organizational leadership
Research
Education
Extended clinical
functions requiring
Extended Class (EC)
registration Clinical Practice Role
Advanced
Nursing
Practice
CNS= Clinical nurse specialist
Bryant-Lukosius, D. 2004 and 2008. The Continuum of Advanced Practice Nursing Roles.
Unpublished document.
The wavy diagonal line in Figure 1 illustrates the fluid or flexible nature of these
roles. By definition, advanced practice nursing roles are dynamic and continually
evolving in response to the changing contexts and healthcare needs of patients,
organizations and healthcare systems (CNA 2008; International Council of Nurses
2008). Our key informants noted that this context-dependent nature of advanced
nursing practice made it difficult to understand the roles. No two CNS or NP roles
are alike, and the balance of clinical and other responsibilities for individual roles
may vary and shift with changing patient health needs and practice priorities in
the work environment.
Title Confusion
Lack of title protection and confusion about CNS and NP titles have been identi-
fied in the past (Schreiber et al. 2005a); however, recent legislation throughout
Canada has protected the NP title, requiring registration as an NP in order to use
the designation (CIHI and CNA 2006). Title protection is not in place for CNSs
(Bryant-Lukosius et al. 2010). Healthcare administrators whom we interviewed
noted inconsistencies in the requirements for and the use of the CNS title that
contribute to the reduced awareness of and lack of role clarity for the CNS role.
In Alberta, the title Specialist is restricted to registered nurses (RNs) practising
in a specialty who have a graduate degree and three or more years of experience
in that specialty (College and Association of Registered Nurses of Alberta 2006);
however, the title Specialist is not limited to the CNS role and may be applied to
other nursing roles such as clinical nurse educators. The absence of CNS-specific
education programs and the lack of title protection for CNSs in Canada have
resulted in contrasting situations where nurses with graduate education and a
clinical specialty are working as CNSs but are not titled as such and, conversely,
others who do not have CNS qualifications claiming to be a CNS. Both the non-
CNS-titled nurse in the role of a CNS and the indiscriminate use of the CNS title
contribute to role confusion within and outside the profession.
Interview and focus group participants widely agreed that the NP is the most
recognized advanced practice nursing title; yet the variety of NP titles for similar
positions across provinces and territories creates confusion for the public and
those in the healthcare system. For instance, a nursing regulator stated,
Some of the issues are actually around the title nurse practitioner, what
does that mean to people, and not only to the community but other disci-
plines as well? Were still using a lot of different titles. Were still using
advanced practice, nurse practitioner, nurse practitioner specialist, nurse
practitioner primary healthcare, nurse practitioner family-all ages. So I
think thats confusing in itself around the title.
Interview participants consistently cited the CNS as the least well known and least
understood advanced practice nursing role, and they described confusion about
the CNS and NP roles, as demonstrated in this quote from a nursing regulator:
I think that the CNS is probably less understood than the NP. I think
theres still some misunderstanding about NP kind of practice, but I think
the CNS role is perhaps not as well known because of the kind of
things that theyre involved in. Theyre involved more in a systems level
and a research level and consultation level, so Im not sure that its well
understood. I think thats shown by the fact that a lot of times people were
demanding an NP position when really what they wanted was a CNS.
A variety of titles for CNS roles were found in the literature (e.g., Schreiber et al.
2005b) and cited by interview participants; examples of the diverse titles included
nurse clinician, advanced practice nurse (APN) and clinical leader, as well
as numerous specialty titles such as diabetic nurse. In the United States, there is
a plan to move to a single role title, Advanced Practice Registered Nurse, by the
year 2015 for all nurse midwife, nurse anesthetist, CNS and NP roles (Advanced
Practice Registered Nursing [APRN] Consensus Work Group and the National
Council of State Boards of Nursing APRN Committee 2008). The educators,
physicians and healthcare team members who participated in our study agreed
that the many different titles were confusing. However, at the same time, they
indicated that using generic language for both CNS and NP roles, such as APN or
CNS/NP (DiCenso 2008; Registered Nurses Association of Nova Scotia 1999), was
not the answer to the problem and in fact contributed to role blurring and further
misunderstanding. Administrator participants felt the use of the title, APN, was
least helpful. A physician commented,
Well, actually I get a little lost in the nomenclature about APNs versus NPs
versus CNSs plus or minus masters. Theyre not well understood I think,
on the medical side, and even for somebody like myself who is actually
involved in and supportive of the idea, I still dont understand a lot of the
nomenclature, what the difference is, what the expectations might be.
Clearly, title confusion and inconsistent titles make it difficult for healthcare team
members and the public to discriminate between CNS and NP roles.
Lack of Role Clarity
In a systematic review identifying barriers and facilitators to advanced practice
nursing role development and practice, Lloyd Jones (2005) identified role ambigu-
ity as the most important factor influencing role implementation. The ambiguity
was related to confusion among stakeholders about the objectives, scope of prac-
tice, responsibilities and anticipated outcomes of the roles (Lloyd Jones 2005).
This was consistent with the key informants in our synthesis, many of whom
directly associated lack of role clarity with lack of planning for the role, explaining
that without clearly defined goals, the outcomes and potential impact of CNS and
NP roles could not be adequately identified or evaluated. Similarly, in a large study
of PHCNPs in Ontario, an important contributor to role clarity was the purpose-
ful matching of the skill and experience of the NP hired into a position with the
practice setting expectations for that role (DiCenso et al. 2003).
Variable stakeholder awareness and competing stakeholder expectations also
contribute to a lack of role clarity (Bryant-Lukosius et al. 2004). When the role
means different things to different people and there is lack of consensus about
role expectations, role conflict and role overload can occur. A healthcare team
member stated,
We had the NPs start to practice before anyone really understood what
the role was. So the individuals were in place and everyone was trying to
figure out what are you going to do, and I dont know that this is true in
every hospital but whenever we introduce a new role it always seems as
though you might be stepping on anothers role.
Participants also indicated that the lack of clarity between the CNS and NP roles
limits the ability to actualize the appropriate and full scope of each role and in
turn leads to issues with role sustainability, particularly within the context of
competing system and fiscal priorities. Lack of clarity regarding NP and CNS
roles can influence decisions about if and how these roles are funded. For exam-
ple, participants identified that while the funding for both CNS and NP roles
is vulnerable to economic downturns, the CNS role is more at risk because the
direct impact of this role on patient care and the organization is not readily visible
to those who do not understand the role. If funders do not understand the full
potential or scope of CNS and/or NP roles, then they may be apt to fund a more
established or well-defined role to attempt to meet their needs.
Healthcare Team Awareness and Acceptance of CNS and NP Roles
Lack of role clarity contributes to an inadequate awareness of the CNS and NP
roles among healthcare team colleagues, and this can influence their acceptance
of the roles and ultimately the success of role integration (Alcock 1996; Goss
Gilroy Inc. Management Consultants 2001; Irvine et al. 2000; Lloyd Jones 2005;
McNamara et al. 2009). Lloyd Jones (2005) notes that role ambiguity may underlie
healthcare professionals negative attitudes toward advanced nursing roles. She
suggests that changes in role boundaries create uncertainty in relation to profes-
sional identity, leading to increased stress and unproductive behaviour such as
communication breakdown.
Multiple reports from our scoping review documented that healthcare team
understanding of CNS and NP roles is a facilitator for role integration (Besrour
2002; Davies and Eng 1995; Jones and Way 2004; Roschkov et al. 2007; Schreiber
et al. 2003). The importance of increasing team awareness about CNS and NP
education, certification, scope of practice, roles and, where relevant, liability
coverage was emphasized (e.g., Centre for Rural and Northern Health Research
n.d.; DiCenso et al. 2003, 2007).
Interview participants (nursing regulators, healthcare administrators, government,
CNSs, ACNPs, PHCNPs) agreed that other health professionals, including nurses,
were not aware of the CNS and NP competencies and scope of practice. A CNS
stated, Were [CNSs] known kind of individually within the programs or within
the hospital, but overall, as a group, we dont have a high enough profile. A PHCNP
discussed patient experiences when going to other healthcare providers for services:
If they [patients] go to the hospital, theyll get the question, Who is your
doctor? I have a nurse practitioner. Well who is your doctor though?
So its not helping when other healthcare providers dont acknowledge
our [NP] role.
Inadequate professional awareness of NP and CNS roles leads to ambiguous role
expectations within healthcare teams, turf protection and concerns about whether
the CNS or NP is practising outside their scope of practice. This is especially
pronounced when roles overlap among healthcare team members. Healthcare
team participants in our interviews expressed their uncertainty about the nature
of NP and CNS roles. They noted that the lack of written information about
credentials, scope of practice and drug formulary approvals contributed to this
uncertainty. They described turf wars as team members renegotiated their roles
and feared their roles would be replaced by a CNS or NP.
To maintain quality and sustainable patient care, participants identified that many
professions are adjusting to role shifts and overlap in the activities carried out
by other healthcare providers (e.g., physicians and NPs, NPs and RNs, CNSs and
RNs, and RNs and practical nurses), engendering understandable fears related to
loss of autonomy and control that can lead to resistance. Participants identified
that ultimately, healthcare team collaboration depends on respect, trust, a mutual
understanding of one anothers roles, a willingness to negotiate specific role func-
tions based on patient needs and team goals, a non-hierarchical structure, and the
perception that everyone is getting more out of it than they are losing.
In the study of PHCNPs in Ontario described earlier (DiCenso et al. 2003), chal-
lenges with other healthcare team members were most often related to role expec-
tations and the lack of role clarity between RNs and NPs, particularly with respect
to the support expected of RNs by NPs in regard to daily activities, and the expec-
tation of RNs that NPs should contribute to nursing care activities when needed.
The lack of role clarity had the potential for a negative impact on team commu-
nication and professional confidence, particularly for newly graduated NPs who
were making the transition from the RN role.
A lack of understanding and support of NP and CNS roles by the nursing
community was documented by others (de Leon-Demare et al. 1999; Haines
1993), and Higuchi et al. (2006) reported role confusion between the CNS role
and other nurses. The staff nurse participants in our interviews did not describe
conflicts or strain with CNSs and NPs, although they did report challenges in
understanding the nature of the roles. Regulators and administrators reported
that some staff nurses perceived NPs as being aligned with medicine and some-
times had difficulty seeing the NPs contribution to nursing. PHCNPs agreed
with the regulators perspective and added that the strained relationship that
sometimes occurred between themselves and staff nurses was also related to salary
differences and feelings of professional alienation among RNs.
Healthcare administrators noted that the NP role was understood more easily once
healthcare providers had interacted and worked with the NP; however, they did not
believe this was the same for the CNSs. Government participants identified a lack of
understanding about the differences between NPs and CNSs among health author-
ity managers and said that both roles were best understood by physicians who
worked closely with them and by healthcare administrators who employed them.
Public Awareness and Acceptance of CNS and NP roles
Inadequate public awareness of CNS and NP roles has also been identified as
a barrier to their integration (Desrosiers 2007; DiCenso et al. 2003, 2007) and
is associated with title confusion and lack of role clarity. All nursing, regulator,
administrator, educator and government interview participants noted the lack of
public awareness of CNS and NP roles. Regulators identified that it was sometimes
difficult for the public to know which services were provided by which nurses, for
example, when both an RN and an NP worked in a primary care setting. This was
also a finding in a study that investigated parental willingness to be seen by an NP
in a pediatric emergency (Forgeron and Martin-Misener 2005). The study authors
found that many parents lacked an understanding of the roles RNs have in an
emergency department, and this hindered their ability to comprehend the role
of NPs. In our study, a variety of interview participants stated that they perceived
there was greater public visibility and awareness of the NP role than of the CNS
role. A CNS working in a First Nations community stated, One of the biggest
barriers that we deal with is that people First Nation communities dont
know what to expect from the [CNS] role itself.
Research conducted primarily on PHCNPs has demonstrated that once informed
about the role, the public is supportive and accepting of it (Canadian Nurse
Practitioner Initiative (CNPI) 2006b; DiCenso et al. 2003; Harris/Decima 2009).
Participants identified public awareness and acceptance as facilitators for role
integration in the healthcare system. For instance, a nursing regulator stated,
Some of the patients are not used to seeing a healthcare provider outside
of their family physician. So for those who are not familiar with the NP
role, theres anxiety over what may be deemed to be a less qualified person
providing services. So its still that referral or assurance that their
physicians know [they are seeing an NP]. Although for the patients who
have experience with NPs, either from coming from other provinces or
other countries where they have NPs, they look for them or they ask for
NPs. And thats actually the group that is most vocal in terms of question-
ing why they dont have any NPs in their communities.
An administrator in a health authority recounted that by making the work of the NP
role visible, public support grew in the region and facilitated role implementation.
Recommendations to Enhance Title and Role Clarity
A number of key recommendations to enhance title and role clarity were identi-
fied through our review of the literature, in key stakeholder interviews and by the
CHSRF roundtable.
A single title to capture all advanced practice nursing roles, such as CNS/NP or
APN, was not supported by our interview participants. Those who had experi-
enced the dual role found the single title confused their co-workers and patients.
A recent policy document written to clarify the role of oncology CNSs and NPs
also recommended avoidance of the term APN as a role title (Cancer Care Ontario
Oncology APN Community of Practice 2009). Clear and consistent CNS and NP
titles and roles would reduce confusion about their purpose and contributions,
and it would enable each to address specific needs of patients and organizations.
Attaining such clarity and consistency would also facilitate streamlining and
standardizing education for NP and CNS roles. The adoption of consistent titles
for NPs across Canada was recommended by the CNPI (2005).
Specific to role clarity, the most frequently and consistently mentioned recom-
mendation at the CHSRF roundtable was that the CNA should lead, in collabo-
ration with other health professional stakeholder groups, the creation of vision
statements that clearly articulate the value-added role of CNSs and NPs across
settings. These vision statements should include specific yet flexible role descrip-
tions pertinent to particular healthcare contexts; this would help address knowl-
edge and implementation barriers deriving from lack of role clarity.
Confusion is likely to occur when CNS and NP roles are not linked to clearly
defined patient and healthcare system goals and when key stakeholders are not
involved in the planning process (Bryant-Lukosius and DiCenso 2004). Tools are
available to assist in effectively planning for and implementing NP and CNS roles.
For instance, a national framework (CNA 2008) is in place to help define CNS
and NP roles, and several toolkits have been developed to guide and assist with
role implementation for NPs (Advanced Practice Nursing Steering Committee,
Winnipeg Regional Health Authority 2005; CNPI 2006a) and CNSs (Avery et al.
2006). In addition, the PEPPA (participatory, evidence-based, patient-focused
process for advanced practice nursing role development, implementation and
evaluation) framework provides a clear process for determining the need for
and implementing new advanced practice nursing roles (Bryant-Lukosius and
DiCenso 2004). The framework has been used successfully to introduce advanced
practice nursing and other advanced provider roles in orthopedic joint replace-
ment (Robarts et al. 2008), cardiac (McNamara et al. 2009) and long-term care
(McAiney et al. 2008). The framework promotes role clarity and understanding
of CNS and NP roles through stakeholder education about the roles and through
improved role planning and healthcare team involvement in developing the role
description. Lloyd Jones (2005) recommends that when new CNS and NP roles
are introduced, clear role definitions and objectives be developed and communi-
cated to healthcare team colleagues.
Government interview participants indicated that a strategic communication
plan about NP and CNS roles is needed to achieve full integration, acceptability
and support for the roles within healthcare teams and to increase public aware-
ness of the roles. All participants echoed this, emphasizing the need for deliberate
communication at the local, provincial and national levels to educate all stake-
holders in order to achieve a broad-based awareness and understanding of the
roles to maximize patient care. There was a strong recommendation by NPs and
CNSs for professional nursing associations to conduct a far-reaching commu-
nication campaign. Media releases were specifically suggested; for instance,
British Columbia issued a media release when the province reached 100 NPs
(Fayerman 2008). A television commercial in Nova Scotia was a first step in
succinctly communicating the NP role to the public and other healthcare provid-
ers (NPCanada.ca 2008). Following up on what the CNPI (2006b) began, develop-
ing a national nursing media campaign to highlight NP and CNS roles, repeated
and/or updated every six months, would enhance and maintain public awareness
of the roles (Matthews et al. 2007). The CHSRF roundtable also recommended
that a communication strategy be developed (via collaboration with government,
employers, educators, regulatory colleges and professional associations) to educate
nurses, other healthcare professionals, the public and healthcare employers about
the roles, responsibilities and positive contributions of CNSs and NPs.
The identification of nursing leaders and physicians to champion the NP and CNS
roles was recommended to facilitate role implementation and integration into the
healthcare team. The following quote from an ACNP typifies a common recom-
mendation made by other participants (nursing regulators, government partici-
pants and healthcare administrators):
Physician champions can do a marvellous job of turning things over with
their own colleagues. Giving people the opportunity of experiencing the
role really is probably the biggest selling point of what you can do with it,
and then being flexible for when you have that role and making sure that
you structure the role so that it truly is an advanced practice role.
At the team level, interview participants suggested a number of strategies to
promote inter-professional relationships between CNSs and NPs and the health-
care team. For example, they suggested that administrators and managers involve
team members in creating a fit between the various scopes of practice repre-
sented on the team and the role of the inter-professional team as a whole in meet-
ing patient needs. Some healthcare team interview participants described their
involvement in educating NPs and CNSs in the clinical setting and appreciated
being involved early in determining what training would be needed; they felt this
collaboration helped them understand the roles.
The study of PHCNPs in Ontario (DiCenso et al. 2003) revealed that the most
important facilitators for improving role clarity were identifying the patient needs
that NPs were expected to meet; understanding healthcare team members prac-
tice styles and readiness to implement an NP role; circulating a written descrip-
tion of the NP role to team members; providing education about the role; and
allowing time for the NP, physicians and other team members to get to know one
another, including their mutual practice styles.
Finally, to familiarize health professionals with the roles, responsibilities and
scopes of practice of their collaborators, the CHSRF roundtable recommended
that curricula across all undergraduate and postgraduate health professional
training programs include components that address inter-professionalism.
Discussion
Though numerous studies have demonstrated the effectiveness and high
levels of patient satisfaction with NPs (Horrocks et al. 2002) and CNSs
(Fulton and Baldwin 2004), title confusion and lack of role clarity pose
substantial barriers to their full integration into the Canadian healthcare
system. These barriers stem from the use of a variety of role titles, the
absence of systematic planning to explicate the specific role definition and
objectives, inadequate communication with healthcare team members
and the public about the role dimensions, and failure to address inter-
professional team dynamics when these roles are newly introduced.
NPs are licensed practitioners and their title is protected. For healthcare
colleagues and the public, this means that those calling themselves NPs have
a specific scope of practice they are licensed to perform, affording a degree
of standardization and clarity to the title. However, confusion arises in the
various terms used to describe NP specialties. For example, in some jurisdic-
tions, NPs who work in the community are known as primary healthcare
NPs, while in other jurisdictions, they are known as family or all-ages NPs.
NPs who work in acute care have for some time been known as acute care
NPs but now are called specialty or specialist NPs or, more specifically, adult,
pediatrics, or neonatal NPs. As time goes on, additional specialty titles may
emerge, such as geriatric NP and mental health NP. Such titles are likely
helpful in conveying the NPs area of specialized knowledge and expertise to
colleagues and the public. To reduce the confusion caused by different titles
for the same specialty and to facilitate national communication campaigns
about NPs, nursing regulators across the country should consider agreeing
on common specialty titles.
Because the CNS title is not protected, health administrators and manag-
ers who are hiring CNSs should ensure that those being considered for the
position meet the basic qualifications of a CNS (i.e., graduate education,
specialty practice area, skills in system change). Consistent application of
these criteria across the country for all CNS job postings would go a long
way to ensuring that those who hold CNS positions are appropriately quali-
fied and would help reduce title confusion. Once the CNS was hired, title
confusion would be further reduced if the position was titled CNS with
specific roles and responsibilities (e.g., diabetes education) incorporated
into the job description rather than into the title. These strategies would
also facilitate national communication campaigns about CNSs. To further
support this, educators are encouraged to develop graduate education
programs specifically designed to prepare CNSs, based on the advanced
nursing practice competencies and specialty practice.
To ensure the clarity of these roles, it is important to develop proposals for
CNS and NP positions at the local level that clearly identify the need for the
role based on a needs assessment, define the role that best meets the identi-
fied needs and goals, plainly describe the role (Bryant-Lukosius and DiCenso
2004; DiCenso et al. 2003), and identify the team strategy for incorporat-
ing the role and how it will fit in the specific setting (Matthews et al. 2007).
Determination of the healthcare teams practice styles and willingness to
accept a new role is important in establishing future role clarity. Inclusion
of healthcare team members and an NP or CNS in the planning and hiring
process has the potential to increase awareness of the role, as well as the need
for and consequently the acceptance of the role.
Inadequate planning for role introduction is a particularly challenging
issue for the CNS role because the role has multiple dimensions that enable
it to address a broad range of patient, nursing, organizational and system
needs. While the flexibility and responsiveness of NPs and CNSs to changing
healthcare needs is advantageous for employers and patients, it can also be
a liability if it contributes to lack of role clarity. Strategies to clarify NP and
CNS roles and to communicate the responsive nature of the roles are needed
at the national, provincial/territorial and local levels.
Nursing leaders and administrators need specific knowledge about the CNS
and NP roles to ensure that the right role is implemented to meet the identi-
fied needs (Gardner et al. 2007; Griffiths 2006). Role selection depends on
knowing the needs, goals and general tasks required to meet the goals. In
general, if the needs and goals of the position require a large component
of direct patient care, with activities that are beyond the legislated scope
of practice of the RN, then the NP is likely the best role to select (Griffiths
2006). If the position primarily requires quality improvement initiatives and
nurse mentorship and consultation, with a smaller component of patient
care, then the CNS is likely the best role to select.
Healthcare team members, including nurses, are not aware of the CNS and
NP scope of practice. A strategic communication plan within organizations,
including detailed orientation for team members, nurses and physicians
is essential to achieve a broad awareness and understanding of the CNS or
NP role that is being introduced and how the role will be operationalized in
that setting. The publics inadequate awareness of the roles (Forgeron and
Martin-Misener 2005; Thrasher and Purc-Stephenson 2007) may lead to
unclear role expectations on the part of patients, particularly with respect to
hospital-based roles such as the CNS and ACNP.
The application of knowledge translation and marketing principles can
effectively guide a communication and marketing strategy for these two roles
(Bero et al. 1998; Dobbins et al. 2004; Fraser Health n.d.; Graham et al. 2006;
Kennaugh n.d.). Nursing associations can play a lead role in bringing together
a Canada-wide advisory panel of knowledge transfer and marketing special-
ists, as well as members of the public, NPs, CNSs, key decision-makers and
healthcare team members to examine available information regarding CNS
and NP roles. This would include an assessment of likely barriers and facilita-
tors to role implementation (Graham et al. 2006; Grol and Grimshaw 2003).
Such an advisory panel could then build a clear and fully developed marketing
plan, clarify similarities and differences between the roles, and ensure focused
and consistent use of information in messages regarding the benefits of CNSs
and NPs. Messages need to be tailored and packaged in different formats to
target specific audiences with clear, concise and jargon-free language.
Lack of role clarity may pose a threat to other healthcare providers; for
example, a number of NP responsibilities overlap with functions tradition-
ally associated with the physician role, such as prescribing medications and
ordering laboratory and diagnostic tests. Flexibility and knowledge regard-
ing collaboration are assets when negotiating new roles in the team (Barrett
et al. 2007; Donald et al. 2009). As NP and physician roles are not the only
roles that overlap, there is a general need to clarify functions and roles
within a team based on patient and healthcare system needs and goals, while
acknowledging individual skills and interests. The CNS and NP roles overlap
in activities associated with advanced nursing practice competencies such as
research, leadership, patient and staff education, care planning and commu-
nity development. The overlap in functions between the CNS and nurse
clinician or educator is also an area for discussion and clarification within the
team, as both roles are typically involved in staff education, implementing
change and providing leadership. Team members and the CNS and/or NP
need to openly discuss the areas of role overlap and the benefits and points of
confusion or concern regarding this overlap. As patient, provider and organi-
zational needs change, team member roles may need to be renegotiated in
order to clarify individual responsibilities and to avoid loss or duplication of
specific components of patient care. Role overlap is not new to the healthcare
team, nor is the need for clear communication and role delineation.
Orientation for the healthcare team and the NP or CNS should flow from
the planning process, with clear communication of the goals and fit. Written
descriptions of the scope of practice, expectations and boundaries of the
new role are helpful for team members. Time is needed for the CNS or NP
to establish a relationship with the physicians and other healthcare team
members and to understand practice styles and routines. Regularly sched-
uled team meetings to discuss existing and emerging patient needs and to
negotiate the roles of team members in meeting the needs can enhance role
clarity and team functioning for all team members.
Conclusion
Title confusion and lack of role clarity pose major barriers when introducing
CNS and NP roles. Specific recommendations from interview participants
and the literature include the development of a vision statement that clearly
articulates the role of CNSs and NPs across settings; the use of a systematic
planning process to guide role development and implementation; the devel-
opment of a strategic communication plan about NP and CNS roles for
healthcare teams and the public; attention to inter-professional team dynam-
ics when introducing these new roles; and the inclusion of components that
address interprofessionalism in all health professional education program
curricula. Consistent use of CNS and NP titles and clarity regarding roles
will facilitate the full utilization of advanced practice nurses in the Canadian
healthcare system.
Acknowledgements
of Nursing Policy in Health Canada. We thank the librarians who conducted
their busy schedules to participate in key participant interviews and focus groups.
Charbonneau-Smith, R. James McKinlay, Dianna Pasic, Julie Vohra, Rose Vonau
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211
Factors Enabling Advanced Practice
Nursing Role Integration in Canada
Hamilton, ON
Director, Canadian Centre of Excellence in Oncology Advanced Practice Nursing (OAPN)
at the Juravinski Cancer Centre
Hamilton, ON
Halifax, NS
Toronto, ON
Julia Abelson, PhD
Hamilton, ON
Ivy Bourgeault, PhD
Ottawa, ON
St-Jrme, QC
Abstract
Although advanced practice nurses (APNs) have existed in Canada for over 40
years and there is abundant evidence of their safety and effectiveness, their full
integration into our healthcare system has not been fully realized. For this paper,
we drew on pertinent sections of a scoping review of the Canadian literature from
1990 onward and interviews or focus groups with 81 key informants conducted for a
decision support synthesis on advanced practice nursing to identify the factors that
enable role development and implementation across the three types of APNs: clinical
nurse specialists, primary healthcare nurse practitioners and acute care nurse prac-
titioners. For development of advanced practice nursing roles, many of the enabling
factors occur at the federal/provincial/territorial (F/P/T) level. They include utiliza-
tion of a pan-Canadian approach, provision of high-quality education, and develop-
ment of appropriate legislative and regulatory mechanisms. Systematic planning to
guide role development is needed at both the F/P/T and organizational levels. For
implementation of advanced practice nursing roles, some of the enabling factors
require action at the F/P/T level. They include recruitment and retention, role fund-
ing, intra-professional relations between clinical nurse specialists and nurse practi-
tioners, public awareness, national leadership support and role evaluation. Factors
requiring action at the level of the organization include role clarity, healthcare setting
support, implementation of all role components and continuing education. Finally,
inter-professional relations require action at both the F/P/T and organizational
levels. A multidisciplinary roundtable formulated policy and practice recommenda-
tions based on the synthesis findings, and these are summarized in this paper.
McMaster University
Hamilton, ON
Hamilton, ON
Oakville, ON
Introduction
Advanced practice nurses (APNs), including both nurse practitioners (NPs) and
clinical nurse specialists (CNSs), have been part of the Canadian healthcare land-
scape for over 40 years. Despite this long history and a substantial body of research
evidence demonstrating their safety and effectiveness (Fulton and Baldwin 2004;
Horrocks et al. 2002), their full integration into our healthcare system has not yet
been realized. As a result, a number of studies have been conducted in Canada to
identify the facilitators and barriers to advanced practice nursing role integration
(e.g., DiCenso et al. 2003; Goss-Gilroy Inc. Management Consultants 2001; Gould
et al. 2007; van Soeren and Micevski 2001). By full integration into the health-
care system, we mean that the advanced practice nursing role is utilized to its full
potential across the continuum of healthcare. However, full integration cannot
occur unless the role is well developed and implemented. The purpose of this
paper, therefore, is to identify the factors that enable role development and imple-
mentation across three types of APNs: CNSs; primary healthcare NPs, also known
as family or all-ages NPs; and acute care NPs, also known as specialty or specialist
NPs, or adult, pediatric and neonatal NPs.
Methods
This paper is based on a scoping review of the literature and in-depth interviews
completed for a decision support synthesis conducted to develop a better under-
standing of advanced practice nursing roles, their current use, and the individual,
organizational and health system factors that influence their effective integration
in the Canadian healthcare system (DiCenso et al. 2010b). An earlier paper in
this issue provides a detailed description of the synthesis methods (DiCenso et
al. 2010c). Briefly, the scoping review of the literature entailed a comprehensive
appraisal of published and grey literature ever written on Canadian advanced
practice nursing roles as well as international literature reviews from 2003 to 2008
(468 papers in total) (DiCenso et al. 2010c). The in-depth interviews and focus
groups involved a total of 81 national and international key informants including
primary healthcare and acute care NPs, CNSs, physicians, other health provid-
ers, educators, healthcare administrators, nurse regulators and policy makers.
All were asked about facilitators and barriers to the integration of NP and CNS
roles within the healthcare system. A multidisciplinary roundtable convened by
the Canadian Health Services Research Foundation (CHSRF) in the spring of
2009 formulated evidence-informed policy and practice recommendations based
on the synthesis findings. For this paper, we synthesized data from the literature
(from 1990 forward) and interviews to identify federal/provincial/territorial (F/P/
T)- and organizational-level enablers to role development and implementation
across the three types of APNs. Recognizing that NP titles are in transition, we will
refer to NPs as primary healthcare NPs (PHCNPs) and acute care NPs (ACNPs).
Because of space restrictions and the large number of enablers for role develop-
ment and implementation, this paper will provide a broad overview. Most of the
enablers are described in detail in topic-specific papers included in this issue, and
all are described in our final report on the CHSRF website (DiCenso et al. 2010b).
Results
Recognizing that the full integration of APNs is dependent on both successful
role development and implementation, enablers for each will be identified below.
Tables 1 and 2 summarize the enablers for role development and role implemen-
tation respectively, and identify whether the enabler needs to occur at the F/P/T
level and/or at the level of the organization, as well as to which type of APN the
enabler applies.
Role Development
Many of the enablers that would enhance advanced practice nursing role develop-
ment need to occur at the F/P/T level including: utilization of a pan-Canadian
approach, provision of high quality education, and development of appropriate
legislative and regulatory mechanisms (Table 1). Systematic planning to guide role
development is needed at both the F/P/T and organizational levels.
Table 1.
Factors enabling role development by level of intervention
and type of advanced practice nursing
Factor Level PHCNP ACNP CNS
Pan-Canadian approach F/P/T X X X
Education F/P/T
Standardized requirements X X X
Match between education and practice X X X
Adequate resources X X X
Interprofessional education X X X
Legislation and regulation F/P/T X X N/A
Planning F/P/T and
organization
Needs assessment and understanding
of role
X X X
Stakeholder involvement X X X
PHCNP = primary healthcare nurse practitioner; ACNP = acute care nurse practitioner; CNS = clinical
nurse specialist; F/P/T = federal/provincial/territorial.
Utilization of a Pan-Canadian Approach
A lack of coordination across Canada was identified by the Canadian Nurse
Practitioner Initiative (CNPI) (2005b) and in the Canadian Nurses Association
(CNA) Advanced Nursing Practice framework (2008) regarding (1) NP recruit-
ment strategies, (2) a national interprofessional health human resource (HHR)
strategy, (3) national NP education standards, and (4) a national NP legislative or
regulatory framework that would ensure consistent titles, scope and roles. While
the CNPI recommendations pertain to NPs, CNS interview participants stressed
the need for similar coordination for CNSs across Canada. Healthcare administra-
tors, CNSs, PHCNPs and ACNPs noted the variability among education programs
and called for standardization and national certification to allow for greater
mobility of APNs across the country.
The CHSRF roundtable recommended a pan-Canadian approach to standardize
advanced practice nursing educational and regulatory standards, requirements
and processes in order to facilitate provider mobility in response to population
healthcare needs and improve recruitment and retention of APNs.
Provision of High-Quality Education
In addition to standardized educational requirements across Canada, enablers
that ensure high-quality education for APNs include a match between education
and practice, adequate resources, and interprofessional education. These have all
been discussed in detail by Martin-Misener et al. (2010) and will be only briefly
summarized here.
Standardized educational requirements
Consistent with the definitions of advanced practice nursing of the CNA (2008)
and the International Council of Nurses (ICN) (2008), APNs should be prepared
at the masters level. While this is the case for all ACNPs and CNSs across Canada,
there is variability in the educational requirements for PHCNPs, with three prov-
inces (Ontario, Newfoundland and Labrador, and Saskatchewan) preparing them
at the baccalaureate and post-baccalaureate certificate level (Donald et al. 2010b).
Standardizing educational requirements for PHCNPs across Canada would ensure
adherence to international expectations of APNs and facilitate their involvement
in all components of the advanced practice nursing role (advanced clinical prac-
tice, research, education, leadership and consultation and collaboration).
Match between education and practice
Educator interview participants pointed out a mismatch between general educa-
tion and specialized practice for all types of APNs. Limited access to specialty
education in Canada means that NPs and CNSs may work in clinical areas in
which they initially lack specialized knowledge and skills. In addition, due to the
limited availability of NP programs in some parts of the country, NPs educated
for primary healthcare are employed in, and expected to have the skill set needed
to practice in, a specialized ACNP role.
While the curricula of NP programs are specially designed to prepare NPs, there is
limited access to CNS-specific graduate education in Canada. Consequently, most
CNSs in Canada complete generic masters degree programs (Bryant-Lukosius et
al. 2010). ACNP and healthcare administrator interview participants commented
that the limited access to CNS-specific graduate education programs combined
with the lack of a CNS credentialing mechanism means that any nurses with
masters degrees in nursing can call themselves CNSs. APN interview participants
noted that CNS-specific programs would provide knowledge and skills to support
role enactment such as system knowledge, program evaluation, project manage-
ment, research inquiry and clinical specialization.
This issue applies to a lesser degree to ACNPs and PHCNPs. Most provinces offer
generic graduate ACNP programs (CNA 2008), where the knowledge and skills
specific to the desired specialty are obtained through learning opportunities such
as clinical placements and preceptorships (Rutherford 2005). The exceptions
are neonatology, which remains a specialized program offered across Canada
(Rutherford 2005), and ACNP training in Quebec, where ACNPs are authorized
to practise only in the area in which they are trained (Allard and Durand 2006;
Ordre des infirmires et infirmiers du Qubec and Collge des Mdecins du
Qubec 2006). The PHCNP programs are generic, which is consistent with the
generalist focus of the role. They do not provide extensive training in specialty
areas; for example, NPs who work in long-term care settings receive relatively little
education specific to gerontology in their NP training. APN interview participants
in our synthesis suggested that the length of current NP programs is adequate, but
increasing the intensity of the practice component via a residency or internship
program would better prepare them for practice expectations after graduation.
Adequate resources
High-quality educational programs are dependent on adequate resources, includ-
ing funding to develop and pay adequate numbers of faculty, preceptors and
mentors (CNPI 2006b; Schreiber et al. 2003, 2005a; van Soeren et al. 2007) and
clinical placement sites that can support competing needs of students from vari-
ous disciplines. As resources become increasingly scarce, interview participants
identified enablers such as sharing of academic resources across universities and
across health disciplines within universities.
Inter-professional education
Interprofessional education was suggested by healthcare administrators, educators
and PHCNPs as a strategy to facilitate effective teamwork and is supported in the
literature (Jones and Way 2004; van Soeren et al. 2007) and by the CNA (2008).
The roundtable recommended that curricula across all undergraduate and post-
graduate health professional training programs include components that address
inter-professionalism in order to familiarize all health professionals with the roles,
responsibilities, and scopes of practice of their collaborators.
Development of Appropriate Legislative and Regulatory Mechanisms
Because CNS practice does not extend beyond the scope of the registered nurse
(RN), regulation is not required for this role. In the absence of regulation or any
other credentialing mechanism for CNSs in Canada, nurses can self-identify as
CNSs even if they do not have the required education and expertise in a clinical
specialty. For this reason, many interview participants, especially CNSs, advocated
for title protection to strengthen role recognition and ensure that those in the role
have the appropriate education and experience. Regulator and educator interview
participants were also concerned about the absence of a standard credentialing
mechanism because of the difficulty it creates in accurately tracking the number
of CNSs in Canada.
With respect to NPs, legislation and regulation are key enablers that allow them
to autonomously practise to their full scope. Many papers in our scoping review
reported legislative and regulatory restrictions on PHCNP scope of practice
(Donald et al. 2010b) and on ACNP scope of practice (Kilpatrick et al. 2010).
While barriers vary across jurisdictions, the most common include
(1) prescribing restrictions, especially the use of drug lists and formularies
legislated at the provincial/territorial level and the prescribing of narcotics and
controlled substances legislated at the federal level, (2) referrals to specialists,
whereby remuneration policies provide for a higher rate for the specialist if
the patient was referred by a physician (Gould et al. 2007; Nurse Practitioners
Association of Ontario (NPAO) 2008a), (3) legal, formal practice agreements that
limit NP practice (Fahey-Walsh 2004), (4) lack of admission and discharge privi-
leges for ACNPs (Sidani and Irvine 1999) and (5) reliance of ACNPs on medical
directives that are onerous to develop and could lead to potentially ineffective care
options, untimely access to appropriate care, blurred accountability for care and
ACNP dissatisfaction (Hurlock-Chorostecki et al. 2008).
In the interviews, administrators asked that legislative and regulatory changes
be made so that NPs can work to their full scope of practice. Regulators noted
that various regulatory bodies need to network and work together on this issue.
Healthcare team members asked that legislated changes in the advanced prac-
tice nursing role be shared with their team members in writing so that everyone
is kept fully informed. Administrators and physicians noted the cumbersome
process around medical directives and their potential for limiting individualized
patient-centred care.
To ensure consistency across Canada for PHCNPs, Thille and Rowan (2008) and
the CNPI (2006b) advocated a pan-Canadian approach to development and
implementation of legislative and regulatory frameworks. For ACNPs, having
a similar certification process for both acute and primary healthcare NPs was
regarded as a pathway to greater recognition and public acceptance (Centre for
Rural and Northern Health Research (CRaNHR n.d).
Systematic Planning to Guide Role Development
Key enablers to NP and CNS role development are the use of a systematic process to
assess patient and community needs and early stakeholder involvement. These are
described more fully by Carter et al. (2010) and will be summarized briefly here.
Needs assessment and understanding of role
Administrator interview participants described how healthcare restructuring
can be crisis-driven, leading to the ad hoc introduction of new health provider
roles. These reactive decisions in the absence of clearly defined goals, sometimes
associated with healthcare dollars that need to be spent quickly or with hasty
responses to health human resource shortages, lead to role confusion and poor
team functioning. Not surprisingly, evaluations of these new roles frequently have
disappointing results because the evaluation is not linked to the original goals for
role introduction (which may never have been identified) and is often premature.
The unfortunate fallout is that promising roles are discontinued, not because they
were ineffective, but because of the failure to use a systematic approach to lay the
foundation for role development, implementation and evaluation.
At the F/P/T and organizational levels, introduction of advanced practice nurs-
ing roles should be based on a systematic assessment of patient and/or community
needs and a clear understanding of the roles (Bryant-Lukosius et al. 2004; Bryant-
Lukosius and DiCenso 2004; Dunn and Nicklin 1995; Mitchell et al. 1995; Patterson
et al. 1999). Interview participants reported that identification of a service need
or practice gap that an advanced practice nursing role could fill was a significant
factor in determining the success of role integration, including the identification of
the best type of APN to fill the position. Participants identified various resources
to facilitate advanced practice nursing role development and implementation,
including a guide to NP role implementation (Advanced Practice Nursing Steering
Committee, Winnipeg Regional Health Authority 2005); a guide to CNS role imple-
mentation (Avery et al. 2006); the PEPPA framework for the development, imple-
mentation and evaluation of advanced practice nursing roles (Bryant-Lukosius and
DiCenso 2004); and an NP implementation and evaluation toolkit (CNPI 2006a).
Consistent with the need for systematic planning at the F/P/T level, the CHSRF
roundtable recommended that health human resources planning by federal,
provincial and territorial ministries of health should consider the contribution
and implementation of advanced practice nursing roles based on a strategic and
coordinated effort to address population healthcare needs.
Stakeholder involvement
Stakeholders include patients and families, advocacy groups, volunteer agencies,
healthcare organizations, the healthcare team, healthcare providers, professional
associations, support staff, administrators, educators and government agencies
involved in health policy and funding (Bryant-Lukosius and DiCenso 2004).
Stakeholder participation at the onset of advanced practice nursing role develop-
ment is critical for ensuring commitment to and providing support for planned
change, even though it may lengthen the process (Cummings and McLennan
2005). Healthcare administrators noted that lack of stakeholder involvement
contributed to lack of role clarity.
Role Implementation
Once an advanced practice nursing role has been developed, numerous factors
influence its successful implementation (Table 2). At the F/P/T level, these include
recruitment and retention, role funding, intraprofessional relations between CNSs
and NPs, public awareness, national leadership support and role evaluation. At
the organizational level, factors include role clarity, healthcare setting support,
implementation of all role components and continuing education. Finally, inter-
professional relations require action at both the F/P/T and organizational levels.
Challenges posed by some of these factors prompted the CHSRF roundtable to
recommend that a pan-Canadian multidisciplinary task force involving key stake-
holder groups be established to facilitate the implementation of advanced practice
nursing roles.
Table 2.
Factors enabling role implementation by level of intervention
and type of advanced practice nurse
Factor Level PHCNP ACNP CNS
Recruitment and retention F/P/T X X X
Funding F/P/T
APN role X X X
Remuneration X X X
Intra-professional relations between CNSs and NPs F/P/T X X X
Public awareness F/P/T X X X
National leadership support F/P/T
Invisibility of CNS role N/A N/A X
Titling X X X
Evaluation of role F/P/T X X X
Role clarity Organization X X X
Healthcare setting support Organization
Leadership support X X X
Networking X X X
Implementation of role components Organization X X X
Continuing education Organization X X X
Inter-professional relations F/P/T and
organization
Working relationship with physicians X X X
Inter-professional collaboration X X X
Team acceptance X X X
PHCNP = primary healthcare nurse practitioner; ACNP = acute care nurse practitioner; CNS = clinical
nurse specialist; F/P/T = federal/provincial/territorial.
Recruitment and Retention
Recruitment and retention challenges were most often identified by regulators
with reference to PHCNPs. They spoke about the overall shortage of nursing
human resources creating difficulty in identifying appropriate candidates for NP
positions. They also noted that widely varying salaries for NPs and unhealthy
work environments contributed to their moving to other regions, resulting in
difficulty meeting the communitys needs. Regulators voiced concern about the
Agreement for Internal Trade (AIT), which facilitates mobility of licensed prac-
titioners across provinces/territories, in that it may accentuate retention issues
by providing opportunities for NPs to move to higher salary regions. Gaps in
the availability of NPs were noted for long-term care and home care sectors.
Thrasher and Purc-Stephenson (2007) identified challenges in recruiting NPs into
emergency departments because NPs were generally unaware of or uninterested
in positions in this setting. While recruitment issues were predominantly at the
F/P/T level, administrators and some physicians at the level of the organization
reported recruitment challenges given the high demand and low supply of NPs.
Table 2 Continued.
CNSs recommended succession planning to mitigate pending CNS retirements,
and ACNPs suggested visiting undergraduate nursing classes and encouraging
them to pursue education to become APNs. The importance of well-defined
recruitment and integration plans, including retention strategies, was empha-
sized (CNPI 2005a), especially for rural underserviced sites and outpost practice
(Osmond et al. 2004; Pong and Russell 2003). One reason for the CHSRF round-
tables recommendation to develop a pan-Canadian approach to education and
regulatory standards was to improve recruitment and retention of these roles.
Funding
Funding issues relate to the funds required to create, support and sustain
advanced practice nursing positions and those related to direct salary support for
APNs and physicians who collaborate with APNs. Specific dimensions of fund-
ing issues as they relate to PHCNPs and ACNPs have been described in detail by
Donald et al. (2010b) and Kilpatrick et al. (2010) respectively.
Advanced practice nursing role funding
For the most part, funding for CNS and ACNP positions comes from global
hospital budgets. Funding for PHCNP positions typically comes more directly
from the provincial/territorial governments. A number of related issues were
identified in the literature and/or interviews, including an inadequate number of
funded positions (e.g., Davies and Eng 1995; DiCenso et al. 2003; Schreiber et al.
2005a), absence of a stable funding mechanism (CNPI 2005a), inadequate fund-
ing of overhead costs, and the cumbersome process required of communities and
health boards to apply for a funded NP position.
In interviews, regulators identified that initial funding to create NP roles was
sometimes available only on a project or start-up basis and that long-term fund-
ing did not always follow. The CHSRF roundtable recommended that advanced
practice nursing positions and funding support be protected following implemen-
tation and demonstration initiatives to ensure stability and sustainability for these
roles (and the potential for longer-term evaluation) once they have been incorpo-
rated into the healthcare delivery organization/structure.
With respect to CNS roles, regulators raised concerns that it had become more
difficult to justify funding for non-direct patient care roles given funding
constraints, while administrators called for a large investment in the CNS role.
Regulators identified that political support and funding allocations to regional
health authorities provided targeted funding opportunities for NPs, but the lack
of government funding for CNS positions was a barrier. Administrators spoke of
inconsistent funding and having to look for funding for advanced practice nurs-
ing roles from their base or global budget. This reallocation of funding from other
roles was not seen as a sustainable approach. The issue is described in more detail
by Kilpatrick et al. (2010) and by Carter et al. (2010).
APNs emphasized the current economic downturn as a significant barrier.
Administrators noted that the economic situation has direct bearing on available
funding and other supports for introducing new positions for APNs and for keep-
ing existing positions. Some of the physicians noted that with funding cutbacks
there was less incentive to hire NPs.
Remuneration
In a study of PHCNPs in Ontario, most supported being paid a salary from the
Ministry of Health and Long-Term Care through a transfer payment to an organi-
zation employer (DiCenso et al. 2003). Less than 5% wanted to bill the patients
for services rendered. Studies in both Ontario and Quebec reported cases where
PHCNPs and ACNPs earn only slightly more than RNs and in some instances less
(DAmour et al. 2007; DiCenso and Matthews 2007). In the interviews, ACNPs
identified a wage disparity among APNs and recommended changing funding
models to ensure wage parity among APNs and with allied health professionals.
Administrators indicated that APN salaries were not attractive, considering the role
responsibilities. PHCNPs suggested that advanced practice nursing salary scales
be developed to ensure NP remuneration was commensurate with their advanced
skills and scope of practice. At the same time, a government interview participant
noted that NP demands for higher salaries were problematic and unjustified and
recommended a consistent funding formula for NPs across different settings. This
would address a regulators concern that low salaries for NPs in some regions have
created turnover and movement of NPs from one region to another.
Administrators emphasized the need for adequate compensation models for
physicians. Physicians in some jurisdictions noted that they were not able to bill
for consulting with NPs and this created a disincentive for working with them.
The literature (e.g., Jones and Way 2004) and many interview participants identi-
fied fee-for-service reimbursement as a barrier to NP integration because shifting
care tasks to NPs sometimes resulted in loss of physician income.
Educators noted that providing incentives to physicians to hire NPs resulted in the
positioning of NPs as employees instead of as colleagues. A government interview
participant identified that payment of primary care incentives to physicians for
preventive care that is often provided by NPs had unintended negative conse-
quences. These consequences are outlined in a policy brief by the NPAO (2008b)
and are described by Donald et al. (2010b). They include the rendering of the NPs
work as invisible and the incompatibility with the inter-professional approach to
care. Another government interview participant noted that remuneration mecha-
nisms need more work to ensure fair compensation across professions working
within teams. This participant also suggested integrated remuneration negotia-
tions where multiple provider groups negotiate compensation together (e.g., what
is the model of primary care we want to achieve and how do we negotiate remu-
neration to achieve this goal and to ensure fair compensation for all parties?).
Intra-professional Relations between CNSs and NPs
In the interviews, administrators and APNs were enthusiastic about the potential
for collaboration between CNSs and NPs in clinical practice, quality improvement
activities, research and education initiatives. In British Columbia, three CNSs and
an NP function in complementary and potentially overlapping roles to care for
cardiac patients. The NP focuses primarily on direct patient care, while the CNSs
work on program development and quality initiatives (Griffiths 2006).
Although many interview participants viewed co-location of CNSs and NPs as
a facilitator to practice, others noted that this accentuated role confusion result-
ing from overlapping clinical responsibilities and perceived redundancy in
roles. Regulators and CNSs voiced concern about the vulnerability of the CNS
role, some of which was attributed to the recent significant attention given to
PHCNPs through the CNPI. Administrators noted that targeted funding for NP
roles, compounded by the legislative attention to the NP role, had diverted atten-
tion from CNS roles. ACNPs reported that hospital budget cuts secondary to the
current economic downturn were resulting in the loss of CNS roles.
An educator interview participant was concerned that within nursing, NPs are
sometimes seen as mini-doctors, while CNSs are viewed as real nurses, creat-
ing a strain between them. CNSs reported greater NP than CNS representation at
policy- and decision-making tables. Government interview participants did not
seem very knowledgeable about CNSs. One noted that work is needed to address
the significant impact that CNSs can have in the system and that the role is not
embedded in the system in the way the NP role is.
APN interview participants suggested potential strategies such as focusing on
how APNs can collaborate with each other; establishing local, regional and
national communities of APN practice; pooling resources to collectively move the
advanced practice nursing profession forward; and hosting shared forums.
Public Awareness
Inadequate public awareness of advanced practice nursing roles has been widely
identified as a barrier to role integration (e.g., DiCenso et al. 2003; Gould et al.
2007; Irvine et al. 2000; Schreiber et al. 2005a; Thille and Rowan 2008). Research
conducted primarily on PHCNPs has shown that once informed about the
role, the public is supportive (e.g., CNA 2008; Davies and Eng 1995; Hurlock-
Chorostecki et al. 2008; Schreiber et al. 2003). This is important, as public opinion
is often a key catalyst for change in public policy and program delivery.
All the APN groups as well as regulators, administrators, educators and govern-
ment interview participants noted the lack of public awareness of the role.
Regulators identified that it was difficult for the public to know which services
were provided by which type of nurse, for example, a family practice nurse and
an NP in a primary care setting. ACNPs felt there was greater public visibility and
awareness of the NP role than of the CNS role.
Government interview participants suggested a strategic communication plan
including public awareness campaigns. APNs recommended that professional
nursing leadership bodies take responsibility for a far-reaching communication
campaign. One administrator in a regional health authority noted that by making
the work of the role visible, public support grew and facilitated role implementa-
tion. Media releases were suggested. The CHSRF roundtable recommended that
a communication strategy be developed (via collaboration with government,
employers, educators, regulatory colleges and professional associations) to educate
the public about the roles, responsibilities and positive contributions of advanced
practice nursing.
National Leadership Support
APNs voiced the need for increased advanced practice nursing representation at
national leadership tables. National leadership played an important role in profil-
ing the NP role through the CNPI and is needed to address a number of issues
such as the growing invisibility of the CNS role and the confusion caused by the
many advanced practice nursing titles.
Invisibility of the CNS role
The expansion of NP roles corresponds with provincial and national primary
healthcare reform policies, funding of NP education programs and roles, and
national investments in role supports such as the CNPI (2006b). Interview partici-
pants including administrators, regulators and government policy makers noted
that similar provincial or national investment in support of CNS roles is lacking.
Bryant-Lukosius et al. (2010) describe the issue of CNS role invisibility in detail.
The CHSRF roundtable recommended that the CNA lead the creation of vision
statements that clearly articulate the value-added role of APNs. Administrators
emphasized the need to increase awareness and better align CNS roles with
important policy issues in which they could have significant impact such as
patient safety, quality of care and advancement of nursing practice. CNSs identi-
fied the need for networking and national support. Concerned about the future
of the CNS role in Canada, the CHSRF roundtable noted that the role requires
further study and recommended that it be the focus of future academic work.
Titling
Donald et al. (2010a) have described the issue of title confusion in detail. Briefly,
interview participants consistently identified the confusion caused by the vari-
ous advanced practice nursing titles, accentuated by co-location of CNSs and NPs
and the emergence of nonadvanced practice nursing roles such as clinical nurse
educators. Using a common title for both CNS and NP roles, such as APN, was
seen as unhelpful, increasing role blurring and misunderstanding.
Evaluation of the Role
The abundant and consistently positive evidence about the effectiveness of APNs
is an enabler to role implementation. We included in an appendix to our report
a listing of randomized controlled trials that evaluated the effectiveness of APNs
with respect to patient, provider and/or health system outcomes (DiCenso et al.
2010b). We identified 78 trials (28 of PHCNPs, 18 of ACNPs and 32 of CNSs), of
which 41 were conducted in the United States (US), 25 in the United Kingdom
(UK), six in Canada and six in other countries. With remarkable consistency
among the trials, APNs improved outcomes or were found to be equivalent to
their comparison groups.
Our review of participant interviews and Canadian literature revealed numerous
directions for future research. They include (1) a focus on newly implemented
models such as the NP-led clinics and CNSNP collaboration, (2) evaluation of
system-level contributions of the CNS, (3) collection of baseline data prior to
advanced practice nursing role introduction to facilitate proper comparisons,
identification of relevant performance indicators, and evaluation of the impact
of nursing care and non-clinical aspects of advanced practice nursing roles rather
than focusing solely on physician replacement activities (Bryant-Lukosius et al.
2004), (4) shifting the research focus from productivity outcomes (e.g., volume of
patients seen) to patient-based quality of care indicators (Evans et al. 2010), (5)
development of a systematic way to track NP impact on service, given that medi-
cal records, especially in primary care settings, are often not designed to capture
what NPs do (Goss-Gilroy Inc. Management Consultants 2001), (6) development
of research programs to better study access and cost-effectiveness of NPs in the
Canadian context (Thille and Rowan 2008) and (7) development of NP-sensitive
outcomes to better understand NP contributions (Sangster-Gormley 2007).
The CHSRF roundtable identified two research-related recommendations. First,
further research should be conducted to quantify the impact of advanced practice
nursing roles on healthcare costs, taking into consideration education, effective-
ness and length of career. Second, focus on the effectiveness of advanced practice
nursing roles should shift away from replacement models and illustrate the value
added of these roles.
Role Clarity
Lack of clarity about the advanced practice nursing role was identified in the liter-
ature and by interview participants as a significant and common barrier to opti-
mal role implementation (Bryant-Lukosius et al. 2004; DiCenso et al. 2003; Dunn
and Nicklin 1995; Schreiber et al. 2005a, 2005b). Donald et al. (2010a) address
this topic in detail in a separate paper in this issue. Recommendations to address
role clarity issues include development of a clear description of the role based
on defined patient and healthcare system needs and stakeholder involvement
(Bryant-Lukosius et al. 2004; Dunn and Nicklin 1995), clear articulation of scope
of practice (CNPI 2005a), involvement of APNs in defining their role (DiCenso
et al. 2003) and organizational support for APN full scope of practice (Lachance
2005). CHSRF roundtable participants were concerned about the need to address
implementation barriers deriving from lack of role clarity. They recommended
that the CNA lead the creation of vision statements to clearly articulate the value-
added role of CNSs and NPs across settings.
Healthcare Setting Support
Leadership support
Lack of organizational, nursing and physician support has been frequently
reported as a barrier to role implementation for all types of advanced practice
nursing roles (Davies and Eng 1995; Hurlock-Chorostecki et al. 2008; Ingram and
Crooks 1991; Reay et al. 2003) and was reinforced by many interview participants.
Carter et al. (2010) describe the issue of leadership support for these roles in detail.
Leadership that enables the full implementation of the advanced practice nurs-
ing role enacts policies that support and legitimize the role and provides strong
management support (Goss-Gilroy Inc. Management Consultants 2001; Hamilton
et al. 1990; Reay et al. 2003). A government interview participant commented on
the value of multi-stakeholder NP integration committees at the regional level.
Networking
A number of networking support systems were suggested in the literature and
by interview participants, including (1) co-location of APNs to prevent isola-
tion (Hamilton et al. 1990; Humbert et al. 2007), (2) mentorship especially for
those in their first role as an APN (Lachance 2005; Reay et al. 2003; van Soeren
et al. 2007), (3) enhanced professional development opportunities (CNA 2008),
(4) establishment of NP or NP/CNS joint committees or special interest groups
to assist with ongoing planning needs and sharing of common issues and (5) a
community of practice to foster professional development.
Implementation of Role Components
Components of the APNs role include direct patient care, research, education,
consultation and leadership activities (CNA 2008). Time allocated for each activity
varies among APNs, but a balance between clinical and non-clinical activities facili-
tates innovative nursing practice (Bryant-Lukosius et al. 2004). Insufficient admin-
istrative support and competing time demands associated with heavy clinical
demands are frequently reported barriers to participating in non-clinical activities
(Bryant-Lukosius et al. 2004; Hurlock-Chorostecki et al. 2008; Pauly et al. 2004).
Carter et al. (2010) describe in detail the importance of administrative support in
enabling implementation of all role components. The struggle to protect time for
non-clinical functions such as research and education was particularly relevant to
ACNPs, who reported that combined with a heavy patient care load these addi-
tional functions created an unrealistic workload and confusion with the CNS role
in the organization. Kilpatrick et al. (2010) discuss this issue in more detail.
Continuing Education
Both interview participants and the literature supported a robust plan for contin-
uing education for APNs, especially those in rural and northern communities
(Schreiber et al. 2005a, 2005b). Martin-Misener et al. (2010) describe this in more
detail. PHCNPs in Ontario identified numerous challenges to obtaining continu-
ing education, including (1) difficulty taking time off work, (2) financial barriers,
(3) the need to travel to a learning venue, (4) family responsibilities, (5) lack of
information regarding course availability, (6) geographical barriers, (7) fatigue
or academic burnout and (8) poor experiences with previous courses (CRaNHR
2006). Schreiber et al. (2003, 2005a, 2005b) noted the need to develop faculty to
provide continuing education for APNs.
Inter-professional Relations
Working relationship with physicians
The working relationship between physicians and CNSs is generally viewed as
complementary and without conflict, most likely because of the lack of overlap
between their roles. In the case of ACNPs, physicians have usually initiated the
introduction of the role because of growing physician shortages and increasing
gaps in care delivery, and are generally very supportive of it. Tensions generally
relate to ACNPs taking time away from direct patient care to participate in non-
clinical activities and medical residents concerns about losing control of patient
care decisions and having to compete with ACNPs for opportunities to perform
medical activities (DAmour et al. 2007). According to jurisdictional and institu-
tional regulations, the extension of activities beyond the RN scope of practice is
achieved for ACNPs through delegation of tasks, using protocols, medical directives
and drug lists (Hurlock-Chorostecki et al. 2008). Both physicians and ACNPs find
this situation suboptimal. Kilpatrick et al. (2010) describe these issues in detail. At
the level of organized medicine, there is little concern voiced about the ACNP role.
With respect to PHCNPs, physician interview participants indicated that posi-
tive, respectful and trusting relationships along with good communication and
willingness to deal with conflict all contributed to PHCNP role implementa-
tion. Nevertheless, a large number of papers described physician resistance (e.g.,
Cusson 2004; DiCenso et al. 2003; Hass 2006; Ontario Medical Association and
Registered Nurses Association of Ontario 2003; Pong and Russell 2003). Principal
reasons for this resistance related to liability concerns (e.g., Bailey et al. 2006;
Martin-Misener et al. 2004; Way et al. 2001), scope of practice issues (DiCenso et
al. 2003), lack of role clarity (DiCenso et al. 2003), funding arrangements (Jones
and Way 2004) and concern about NP independent practice (Gosselin 2001;
Lagu 2008). These are described in detail by Donald et al. (2010b).
At the level of organized medicine and nursing, professional associations are
responsible for protecting their members interests (Baerlocher and Detsky
2009). As a result, medical associations have opposed initiatives to facilitate full
enactment of the PHCNP scope of practice (e.g., open prescribing privileges) or
improve patient access to care in communities with physician shortages through
models such as NP-led clinics (DiCenso et al. 2010a). A government interview
participant called for both the nursing and medical profession leadership to shift
the culture from a competitive to a collaborative stance.
Inter-professional collaboration
An extensive body of literature describes involvement of APNs in inter-profes-
sional collaboration (e.g., CNA 2008; Jones and Way 2004; MacDonald et al.
2005b). A CHSRF decision support synthesis on inter-professional collaboration
and primary healthcare summarizes high-quality evidence demonstrating positive
outcomes for patients, providers and the healthcare system and identifies a variety
of processes and tools to support the planning, implementation and evaluation of
effective, inter-professional collaborative partnerships (Barrett et al. 2007). There
was a consensus among interview participants about the importance of inter-
professional collaboration. CNSs saw it as essential to achieving the breadth of
their scope of practice, and APNs and physicians saw it as facilitating NP practice.
Government interview participants acknowledged the need to develop a specific
skill set to work collaboratively and they, along with regulators, suggested team
facilitators. Administrators, educators and PHCNPs also identified the importance
of inter-professional education. There was a perception among government inter-
view participants that where NPs have been introduced as part of new primary
healthcare teams, implementation seems to have gone smoothly.
Tensions can develop around who leads the team. Physicians are accustomed to
being the team leads. As Hutchison notes,
the move toward collaborative and team-based approaches to care
requires a culture shift that will be especially challenging for physicians
who are accustomed to being the undisputed team leader. In an interdisci-
plinary environment, involvement of other professional and administra-
tive staff in policy and management decisions is no longer discretionary
(2008: 1314).
Team acceptance
Lack of healthcare team awareness of APN roles has been identified frequently
as a barrier to role integration (e.g., Davies and Eng 1995; DiCenso et al. 2003;
Hass 2006; Hurlock-Chorostecki et al. 2008; Jones and Way 2004; MacDonald
et al. 2005a; Wall 2006). There was consensus among regulators, administrators,
government policy makers and APNs that other professionals, including nurses,
were not aware of the scope of the APNs practice. Administrators noted that
the NP role was understood more easily once people had worked with the NP;
however, they did not believe this was the same for CNSs. Among the six govern-
ment interview participants, this awareness issue was the most commonly identi-
fied barrier to successful APN integration. They believed that health authority
managers lacked understanding of the differences between NPs and CNSs and
that the roles were understood only by physicians who worked closely with them
and by administrators who employed them.
The healthcare teams understanding of the APN role has been widely identified
as a facilitator to role integration (e.g., Davies and Eng 1995; DiCenso et al. 2003;
Humbert et al. 2007; Hurlock-Chorostecki et al. 2008; Nova Scotia Department
of Health 2004; Ontario Medical Association and Registered Nurses Association
of Ontario 2003). The importance of increasing professional awareness about the
APNs education, certification, scope of practice, roles and, where relevant, liability
coverage has been emphasized (e.g., CNA 2008; Cummings et al. 2003; Nova Scotia
Department of Health 2004; Ontario Medical Association and Registered Nurses
Association of Ontario 2003; MacDonald et al. 2005a; Schreiber et al. 2005a).
Government interview participants indicated that a strategic communication plan
about advanced practice nursing roles is essential to achieving full integration,
acceptability and support. There was consensus among interview participants on
the need for strategic communication to educate all stakeholders in order to achieve
a broad-based awareness and understanding of the role. The CHSRF roundtable
agreed, recommending development of a communication strategy to educate
nurses, other healthcare professionals and healthcare employers about the roles,
responsibilities, and positive contributions of advanced practice nursing roles.
Regulators, government policy makers, administrators and ACNPs also recom-
mended enlisting nurse leaders and physicians as champions to promote the roles.
Discussion
This decision support synthesis provided the opportunity to identify the
barriers and enablers to integration of all three types of APNs in Canada and
permitted identification of both common and unique factors across APN
type. While we focused on Canadian literature and key informants, there is
remarkable consistency between our findings and those reported by Lloyd
Jones (2005) in a systematic review of 14 qualitative studies, mostly from the
UK, reporting barriers or facilitators to role development and implementa-
tion of APNs in acute care hospital settings. With respect to role develop-
ment, similar issues include (1) absence of educational standardization for
roles, (2) lack of relevant courses, education-related resources and mentors,
(3) perceived ambivalence of professional regulatory bodies and (4) lack of
clear role definition, boundaries and expectations causing role ambiguity. A
knowledge base in the relevant specialty was identified as a facilitator. With
respect to role implementation, similar issues include lack of full-time fund-
ing for the role, inadequate salaries relative to responsibilities, lack of mana-
gerial support, lack of networks, isolation, heavy clinical workload prevent-
ing engagement in non-clinical role activities, physician resistance and lack
of effective inter-professional relationships.
Consistent with the international interest in advanced practice nursing roles,
the Organisation for Economic Co-operation and Development (OECD)
gathered data in 2009 from 12 countries (Australia, Belgium, Canada, Cyprus,
Czech Republic, Finland, France, Ireland, Japan, Poland, the UK and the
US). Its purpose was to (1) identify factors motivating the development of
advanced practice nursing roles, (2) describe the state of development of these
roles in the participating countries, (3) review the results from evaluations
of the impact of advanced practice nursing on healthcare access, quality and
costs and (4) examine the factors that have hindered or facilitated the devel-
opment of these roles (Delamaire and Lafortune 2010). With respect to the
factors influencing role development, they identify four, all consistent with the
findings of our synthesis: (1) the professional interests of doctors and nurses
and their influence on reform processes, (2) the organization of care and
funding mechanisms, (3) the impact of legislation and regulation of health
professional activities on the development of new roles and (4) the capacity of
the education and training system to provide nurses with higher skills.
With respect to professional interests, most professions are having to adapt
as boundaries between professional jurisdictions are continually rene-
gotiated and all struggle for clear identities (Beaulieu et al. 2008). This
engenders understandable fears related to loss of autonomy and control,
and leads to resistance. Baerlocher and Detsky (2009) describe turf battles
between and within professions when they compete to perform the same
task. They explain that reliance on self-governing professional bodies to
determine appropriate work boundaries is problematic. They may have no
reason to cooperate with one another, and solving workforce problems this
way requires successful negotiation that keeps the publics rather than the
professions interest in mind. Hutchison (in press) has suggested that the
government establish a mechanism to bring together both physician and
non-physician primary healthcare providers to advise on primary healthcare
policy development and implementation. He states that
rather than dealing with policy makers through separate, private
bilateral discussions, stakeholders would be obliged to hear each
others perspectives and would be under pressure to serve the public
good by constructively addressing areas of conflicting interest
(Hutchison in press).
Advanced practice nursing roles in Canada are becoming more fully inte-
grated in the healthcare system. For example, in December 2009 the Yukon
Territory was the last of the provinces and territories to pass legislation
regulating NPs. The Canadian healthcare system is facing significant chal-
lenges, many of which require the optimal use of all members of the health-
care team. We face public calls for increased and more equitable access to
care and reduced wait times as well as increased demands for service related
to the aging population, chronic illnesses (e.g., cancer, arthritis, diabetes
and heart disease) and mental health problems. There is also a societal
shift toward wellness care and the provision of support to patients for self-
management. Canada is a vast country with many underserviced, rural and
remote populations. At the same time, we face physician and nursing short-
ages and a continued maldistribution of practitioners, especially in northern
Canada (Canadian Institute for Health Information 2006; College of Family
Physicians of Canada 2004; Kulig et al. 2003).
These developments increase the complexity of coordinating care delivery
and ensuring that each member of the healthcare team is being deployed in
an efficient and effective manner to maximize patient health. This requires a
strong awareness of the roles of each member of the team. It calls for a coor-
dinated health human resources strategy that ensures the appropriate mix of
providers for the specific setting and community/patient needs, and this has
implications for forecasting education needs.
While there is still much to do to address the remaining barriers to the full
integration of APNs, there exists a receptive dynamic climate. For example,
in April 2009 when we completed the decision support synthesis, PHCNPs in
Ontario were restricted to prescribing from drug lists. However, in December
2009, Bill 179 the Regulated Health Professions Statute Law Amendment
Act received royal assent. It gives Ontario NPs open prescribing privileges
and eliminates laboratory and radiology lists by 2011 (Ontario Ministry of
Health and Long-Term Care 2009). Furthermore, the Ontario government is
currently reviewing hospital inpatient admission and discharge privileges for
NPs (Ontario Ministry of Health and Long-Term Care 2010).
The CHSRF roundtable recommendations include (1) clearly defined roles
and reduced confusion related to the many titles used for APNs, (2) role
development and introduction guided by a systematic process to assess
patient/community needs, including early stakeholder involvement,
(3) consideration of the contribution and implementation of advanced
practice nursing roles in federal and provincial/territorial health human
resources planning, (4) strategies to improve awareness about the role
among health professional colleagues and the public, (5) stable funding
mechanisms for the role, (6) standardized regulation, (7) standardized grad-
uate education, (8) inter-professional education and (9) research to inform
the value added of these roles and to inform the CNS role in Canada.
Creativity will be required to address some of the more challenging issues. For
example, given the size of Canada, its relatively small number of APNs, and
the large number of specialty areas, how can specialized practice be taught in
the context of generalized educational programs? What CNS credentialing
mechanism can be introduced to ensure that those in the role have the appro-
priate education and experience? How can we implement a successful pan-
Canadian approach to standardize education and regulation for APNs, given
that healthcare is the mandate of individual provinces and territories?
This decision support synthesis has provided an opportunity to consolidate
the literature and obtain the input of key informants to identify factors that
have enabled advanced practice nursing role development and implementa-
tion and those that continue to impede full integration of APNs. Based on
these data, the multidisciplinary CHSRF roundtable formulated a number
of recommendations. We now look to nursing leaders in Canada to facilitate
the implementation of these recommendations and ultimately the full inte-
gration of APNs in the Canadian healthcare system.
Acknowledgements
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239
Utilization of Nurse Practitioners
to Increase Patient Access to
Primary Healthcare in Canada
Thinking Outside the Box
Hamilton, ON
Ivy Bourgeault, PhD
Ottawa, ON
Julia Abelson, PhD
Hamilton, ON
Halifax, NS
Hamilton, ON
Hamilton, ON
Oakville, ON
Abstract
In the past decade, all Canadian provinces and territories have launched various
team-based primary healthcare initiatives designed to improve access and continu-
ity of care. Nurse practitioners (NPs) are increasingly becoming integral members of
primary healthcare teams across the country. This paper draws on the results of a
scoping review of the literature and qualitative key informant interviews conducted
for a decision support synthesis about advanced practice nursing in Canada. We
describe and analyze two novel approaches to NP integration designed to address
the gap in patient access to primary healthcare: (1) the integration of NPs in tradi-
tional fee-for-service practices in British Columbia, and (2) the creation of NP-led
clinics in Ontario. Although fee-for-service remuneration has been a barrier to
collaborative practice, the integration of government-salaried NPs into fee-for-
service practices in British Columbia has enabled the creation of inter-professional
teams, and based on early evaluation findings, has increased patient access to
care and patient and provider satisfaction. NP-led clinics are designed to provide
inter-professional care in communities with high numbers of patients who do not
have a regular primary healthcare provider. Given the shortage of physicians in
communities where these clinics are being introduced, the ratio of physicians to NPs
is lower than in other primary healthcare delivery models, and physicians function
in more of a consulting role. Initial evaluation of the first of 26 NP-led clinics indi-
cates increased access to care and high levels of patient and provider satisfaction.
Implementing a creative mosaic of collaborative primary healthcare models that are
responsive to patient needs challenges traditional assumptions about professional
roles and responsibilities. To address this challenge, we endorse a recommendation
that governments establish a mechanism to bring together both physician and non-
physician primary healthcare providers to advise on primary healthcare policy devel-
opment and implementation.
Toronto, ON
Hamilton, ON
St-Jrme, QC
241 Utilization of Nurse Practitioners to Increase Patient Access to Primary Healthcare in Canada Thinking Outside the Box
Introduction
Patient access to primary healthcare is a significant issue in Canada. In the 2007
Commonwealth Fund International Health Policy Survey conducted in seven
countries (Australia, Canada, Germany, the Netherlands, New Zealand, the
United Kingdom [UK] and the United States [US]) (Schoen et al. 2007), 84%
of Canadian adults reported that they had a regular doctor at the time of the
survey, second lowest of all the countries (the US was the lowest, at 80%, and the
Netherlands highest, at 100%). Canadian adults were the least likely to report
same-day access and most likely to report long waits (six days or more) to see a
doctor when sick, and along with Americans and Australians, were the most likely
to report difficulty getting after-hours care. Canadian adults were the most likely
to have gone to a hospital emergency department (ED) in the past two years, to
have made multiple visits, and to say they went to the ED for care their doctor
could have provided if available. These high rates are contributing to long ED wait
times, with 46% of Canadians (the highest of all the countries) reporting waiting
two hours or more in the ED to be seen (Schoen et al. 2007).
In the 2008 Commonwealth Fund International Health Policy Survey of eight
countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, the
UK and the US), data were collected from adults with chronic conditions (Schoen
et al. 2009). Patients from Canada and the US were the least likely to report same-
or next-day access, and Canadian adults were the most likely to have waited six
days or more, or to never have obtained an appointment to see a doctor the last
time they were sick. Again, Canadians were most likely to go to the ED for a condi-
tion that could have been treated by their regular doctor if available.
Consistent with the emphasis on teams to manage chronic conditions, the survey
examined the use of expanded roles for nurses to counsel and to provide and
coordinate care. Canadian adults, along with Australians and Germans, were least
likely to report having a nurse or nurse practitioner (NP) regularly involved in
managing their condition, in comparison to UK adults who were the most likely
to report nurse involvement (22% of Canadian versus 48% of UK adults). The
low use of nurses/NPs in chronic disease management in Canada is particularly
of concern given that, unlike most Organisation for Economic Co-operation
and Development (OECD) countries, physician density in Canada remained
unchanged between 1990 and 2005 (2.1 practising physicians per 1,000 popula-
tion) whereas the OECD average increased from 2.2 to 2.9 (Dumont et al. 2008).
In 2004, the first ministers (the prime minister and premiers) of Canada agreed
that timely access to primary healthcare was a high priority for all jurisdictions
and set the objective that 50% of Canadians would have 24/7 access to multidis-
ciplinary teams by 2011 (First Ministers Meeting on the Future of Health Care
2004). There is a growing body of evidence about the effectiveness of inter-profes-
sional teams in delivering primary healthcare. In a decision support synthesis on
this topic, Barrett and colleagues (2007) found that inter-professional collabora-
tion models enable delivery of a broader range of services, more efficient resource
utilization, better access to services, shorter wait times, better coordination of care,
more comprehensive care and better health outcomes for patients, compared to a
uni-professional model of primary healthcare delivery.
In the past decade, all Canadian provinces and territories have launched various
team-based primary healthcare initiatives designed to improve access and conti-
nuity of care (Beaulieu et al. 2008). NPs are increasingly seen as integral members
of primary healthcare teams across the country. While they have worked for many
years in long-established primary healthcare organizations such as community
health centres (CHCs), the quest to increase patient access to care has recently
stimulated novel approaches to NP deployment. In this paper, we use data gath-
ered from published and grey literature and key informant interviews to describe
and analyze two novel approaches to NP integration: (1) the introduction of NPs
into traditional fee-for-service practices in British Columbia, and (2) the creation
of NP-led clinics in Ontario. We have selected these two as unique illustrations
of primary healthcare collaborative models that involve NPs and are specifically
designed to address the gap in patient access to care.
Methods
This paper draws on the results of a scoping review of the literature and qualitative
key informant interviews conducted for a decision support synthesis commis-
sioned by the Canadian Health Services Research Foundation and the Office of
Nursing Policy in Health Canada. The overall objective of this synthesis was to
develop a better understanding of advanced practice nursing roles (which in
Canada include NPs and clinical nurse specialists), their current use, and the indi-
vidual, organizational and health system factors that influence their effective devel-
opment and integration in the Canadian healthcare system (DiCenso et al. 2010a).
The methods undertaken for this synthesis are described in detail in an earlier
paper in this issue (DiCenso et al. 2010b), but in brief, they included a comprehen-
sive examination of all published and grey literature on advanced practice nursing
roles in Canada to the end of 2008 and recent reviews of the international litera-
ture (2003 to 2008). Interviews and focus groups were also conducted with 81
national and international key informants, including NPs, clinical nurse special-
ists, physicians, other health providers, educators, health administrators, nursing
regulators and policy makers. For this final paper in this special issue reporting on
various aspects of the synthesis, we took a slightly different approach. On the basis
of questions asked of interview participants about current pressures facing the
healthcare system and examples of successes in the implementation of advanced
practice nursing roles, we identified two recently developed collaborative models
that utilize primary healthcare NPs (PHCNPs) to increase patient access to care.
Since these are new models of care, there is very little published literature describ-
ing them, and only preliminary evaluations have been completed to date. To
learn more about these models, subsequent to the completion of the synthesis
we conducted Internet searches (e.g., Ontario government website about NP-led
clinics and Interior Health regional health authority website about NPs in fee-for-
service practice) and follow-up telephone and e-mail conversations with seven
participants associated with these models to ensure more complete and accurate
descriptions and analysis. These participants included NP and physician clinicians
working in these care models and individuals charged with model implementa-
tion. They provided background and descriptive information and commented
on the presentation of the models in this paper. We present a descriptive analysis
of the development, evolution and early experiences of these two models of care.
To the extent possible given the models brief existence, we summarize facilita-
tors and challenges in establishing and sustaining these models and outline their
strengths and limitations. While we describe preliminary evaluations, the intent of
this paper is not to evaluate the models, given their recent introduction.
Results
Integration of NPs in Fee-for-Service Primary Healthcare Practices
When NPs were first introduced into urban settings in Ontario in the early 1970s,
they were paid by physicians who earned their income through fee-for-service
(FFS). Although NPs were shown to safely manage patient problems, maintain
patient satisfaction and increase patient access to care (Chambers and West 1978;
Spitzer et al. 1973a, 1974b), integration of this role failed, primarily because of this
funding arrangement for NP services.
Under publicly funded FFS, the physician bills the state authority (e.g., the provin-
cial governments universal health insurance plan) for each service provided
(Beaulieu et al. 2008). The physician may decide to delegate activities to others;
however, he or she must be present at some point in the assessment to qualify for
payment. When Spitzer et al. (1973b, 1974a) found that the income of six private
practices employing NPs declined slightly during a two-year period, it was attrib-
uted in part to health insurance billing restrictions for unsupervised services
rendered by the NP (Spitzer et al. 1974a). In a study of the financial impact of
NP employment on the practices of six FFS family physicians in Newfoundland,
Chambers (1979) similarly found that losses occurred in the fee-for-service
method of physician payment environment that discourages delegation of tasks
(Chambers 1979: 347). Since FFS physicians were unable to bill directly for
services provided by NPs and had to pay the NPs out-of-pocket, hiring NPs was
financially disadvantageous (van der Horst 1992), posing a significant barrier
to NP role implementation (Advisory Committee on Health Human Resources
and The Centre for Nursing Studies in collaboration with The Institute for the
Advancement of Public Policy, Inc. 2001; de Witt and Ploeg 2005; DiCenso et al.
2003; Goss Gilroy Inc. Management Consultants 2001; Gould et al. 2007; Jones
and Way 2004; MacDonald et al. 2005; Schreiber et al. 2005).
Key to integrating an NP into an FFS practice is that the volume of patients seen
by the physician does not decrease, as this results in income loss for the physician.
NP integration into an FFS practice is best achieved when the practice is full and
there are unattached patients (i.e., those without a primary healthcare provider)
in the community who can now be added to the practice. As one of our nursing
regulator participants describes,
Well, it acts as a barrier because the physicians income is based on volume,
so hes not going to want to have a nurse practitioner take away some of
his business, if we call it that, because thats income that he would have.
A physician we interviewed also aptly notes,
If you want doctors to not support [NPs], then you say that funding for
NPs is going to take away dollars for doctors and, of course, thats human
nature people are not going to support it.
More recent NP integration strategies have involved payment of the NPs salary by
the government to work in primary healthcare practices where physicians are paid
through mechanisms other than FFS, such as salary or capitation (a fixed payment
made at regular intervals by the government for each enrolled patient, regardless
of services provided). While many primary healthcare physicians have moved into
these alternate payment plans, the 2007 National Physician Survey revealed that
half (48.3%) still derive at least 90% of their income from FFS payment (College
of Family Physicians of Canada et al. 2007). Some physicians who continue in FFS
practices have indicated an interest in working with NPs. For example, of 355 FFS
physicians in Ontario who responded to a survey in late 2002, 42.3% indicated
they would be interested in working with NPs (DiCenso et al. 2003).
In 2000, when the Ontario government announced funding for 106 NP positions
in underserved communities, a small number of these were introduced into FFS
practices. The government paid the NPs salary and some overhead costs, while
the physician continued to be paid through FFS. In a survey of Ontario NPs in
late 2002, 10.7% of 234 NP respondents indicated they were working in a FFS
physician practice. Site visits were made to four of these practices. In one practice,
the NP worked with one physician and provided education and chronic disease
management to patients with one specific medical condition, while in the other
practices, the NPs worked as generalists, seeing 12 to 15 clients a day. When asked
about the benefits of working with an NP, FFS physicians were more likely to indi-
cate that NPs increased the number of patients seen than were physicians in other
types of primary healthcare funding arrangements (DiCenso et al. 2003).
Given the number of physicians still remunerated through FFS and the need to
improve patient access to care in the short run, other provinces have begun to
integrate NPs into FFS practices. For example, in Alberta, NPs are part of Primary
Care Networks in which the physicians may be paid by FFS. In British Columbia
(BC), at least four regional health authorities (RHAs) have introduced salaried
NPs (n = 12) into FFS physician practices. The experience of Interior Health RHA
is illustrative in this regard.
General Description of This Model
In July 2007, Interior Health RHA introduced the Nurse Practitioner/Family
Physician Primary Health Care Model, in which salaried NPs work in FFS physi-
cian group practices. To date, four NPs have been hired, with two working in
group practices in Trail, one in Castlegar and the fourth in Kelowna. Three of
the NPs are functioning in generalist roles in the practices, and one does rapid
response home visits to the frail elderly through the Seniors-at-Risk Initiative.
The NPs are employees of the RHA hired in collaboration with the FFS physicians.
They function under the terms and conditions of the RHA, which pays their salary
and benefits. Physicians complete a proposal providing the rationale for incor-
porating an NP in their practice. If the proposal is approved, funds are provided
annually by the RHA to the practice to cover NP overhead costs such as medical
office assistant support, space, supplies and equipment. If the NP consults with
the physician about a patient with complex care needs, there is provision for the
physician to bill once annually per complex care patient for consultation, with-
out seeing the patient. If a patient who is not identified as a complex care patient
presents with an acute illness which leads the NP to consult with the physician,
the physician will see the patient and bill for that service. No additional funds are
provided to the physician by the RHA for time spent consulting with the NP.
When patients request appointments, the medical office assistant, who is knowl-
edgeable about the NPs scope of practice, offers suitable patients an appointment
with the NP. Patients are assigned to the NP; however, patients may be seen by
either the physician or NP depending on their presenting problem at the time of
each visit. In the case of the Seniors-at-Risk Initiative, seniors are referred to the
NP by community physicians, home care, patients and/or family, and the three
physicians whose clinic the NP is affiliated with.
The NP facilitates changes in the delivery of care, addresses patient self-manage-
ment goals, links with other health resources in the community, provides compre-
hensive primary healthcare focusing on health promotion and illness prevention,
coordinates activities by providing ongoing case management to those requiring
complex care, refers to specialists as required, and provides unique learning and
health promotion opportunities for nursing students. One of the physicians work-
ing in this model described the working relationship with the NP:
The NP is paid for by the RHA. We have 1,800 patients. She increased
my capacity by about 600 patients. She is actually the most responsible
provider for over 400 patients. I see about 3035 patients in the office
per day. The NP sees about 15. Three to five of the patients that she sees,
she has me see with her. It usually takes less than five minutes, and I bill
a routine office visit. She does all the work in those cases ... prescribing,
ordering tests, arranging follow-up and consultations. We often discuss
patients throughout the day (no charge) and [it is] very gratifying to have
two heads on the case. Shared responsibility. I often ask the NP to consult
on patients that I see during the day, and I arrange follow-up with her for
our complex patients as she has longer appointments and more expertise
in congestive heart failure, diabetes and womens health. The NP is an
equal. She accepts responsibility for the administration of the office as
well. It is a fabulous, complementary and symbiotic relationship. Our
patients are better cared for with less hospital admissions and ER visits and
improved, often same day or next day access. The NP is helping with
hospital rounds and co-rounds, and we are both very involved in teaching.
I am enjoying practice now more than ever! We need to break down myths
with our MD colleagues. The arguments regarding stealing patients, need-
ing too much supervision, not having enough time, etc., are old. It is just
not true. I make more income and the job is easier and more fun.
An NP in an FFS practice added the NP perspective:
There are many days that I do not ask the physician to review a patient
case with me. This seems to change given the acuity of my day. Many days
are filled with follow-up or chronic care planning, while others will fill
quickly with more acute or urgent requests. The policy in the office is that
you are offered the first available appointment. If the issues presenting are
beyond the scope of the NP, I can still do a history and physical exam, and
start any diagnostic required. Then, in less than five minutes the physician
can confirm and/or suggest other possible treatments. This is all done in
the original appointment, thus eliminating the need to come back to see
the physician at a separate time. The follow-up may be with the NP or the
physician, depending on the presenting problem. The key is the patient
has been part of our collaboration and they see us working as a team in
their best interest where no one person has the right answer. Instead,
we are looking for the best solution to the problem. Further, this model
has allowed us to move beyond episodic care to more preventive care. It
has also provided many opportunities to educate our patients and others
about the value of collaborative practice.
Interior Health RHA has completed the first of a three-phase evaluation of this
model of care (Hogue et al. 2008). This first phase evaluation was completed at 12
months post-implementation and utilized qualitative data collected through focus
groups and individual interviews of health providers and patients. Similar to the
quotes noted above, healthcare professionals involved in this model of care reported
an increase in job satisfaction, mutual trust and respect between practitioners, open
positive communication between the NP and physician, and a heavier focus on
patient-centred care. Patients felt they had improved access to healthcare services,
more time with a practitioner in one appointment and more comprehensive health-
care, and they felt they were a part of their healthcare team (Hogue et al. 2008).
Facilitators to Establishing and Sustaining This Model
NP role implementation was facilitated by the leadership of the RHA, which set
out a clear process for role introduction and evaluation, and through the follow-
ing activities: establishing supportive policies, infrastructure and practice environ-
ments; promoting team functioning and mutual respect for the knowledge and
practice of team members; maintaining open and regular formal and informal
communication; and clarifying roles on an ongoing basis (Pawlovich et al. 2009).
Challenges to Establishing and Sustaining This Model
The evaluation described above revealed challenges to successful integration of
NPs into an FFS physician group clinic (Hogue et al. 2008). One persistent chal-
lenge related to the prevailing historical roles within the health system is that the
physician is situated at the top of the hierarchy. However, study participants indi-
cated this is slowly changing. Physicians worried that collaboration would increase
their workload or expose their knowledge gaps. They were concerned that, while
the scope of practice of the NP was similar to theirs, NPs had less formal train-
ing. Finally, patients felt that if they continued using NP services, they would lose
their spot with the physician.
In their evaluation, Hogue et al. (2008) identified a need for more formal infor-
mation and education for healthcare professionals and the public about the NP
role. Suggestions to strengthen the implementation strategy included (1) creating
a shared physician lead (rather than identifying a lead physician to champion the
NP role) to allow all the physicians at the clinic to feel more invested and to fully
collaborate with the NP, and (2) involving all members of the clinic at the outset
to discuss role clarification and to develop a mission statement and concrete goals
for the clinic. Strategies to enhance communication among the team included
initial orientation about the NP role with all clinic members, ongoing education
related to collaborative practice and regular staff meetings. Finally, an additional
strategy to gain NP acceptance among the medical community was to involve
physicians in supporting an NP student in their clinic (Hogue et al. 2008).
Strengths of This Model
Very little research has been conducted on this model of care, and more is
warranted in order to fully explore its merits and limitations. Experience to date in
BC indicates that (1) although FFS remuneration has been identified as a barrier
to collaborative practice (Barrett et al. 2007), the addition of a government-sala-
ried NP into an FFS practice enables the creation of inter-professional teams,
(2) NP integration into these practices has increased patient access to care, which
is often available on the same day, possibly reducing visits to the emergency
department for primary healthcare needs, (3) team members offer complemen-
tary skills in caring for patients, for example, in chronic disease management and
(4) based on the first phase evaluation in the Interior Health RHA, patients feel
better informed about their health and feel a part of the decision-making process
related to their care, and providers have increased job satisfaction.
Limitations of This Model
Potential limitations of this model include (1) concern over physicians loss of
income if the NP instead of the physician is seeing the patients. This assumes a
finite number of patients and patient demands, which is not necessarily the case;
this is best illustrated by NP integration in communities where there are many
unattached patients, some of whom can now be taken on by the practice;
(2) concern over physicians loss of income if spending time providing consulta-
tion to the NP rather than seeing patients. This can be addressed with a set amount
of money paid to the physician by the government on a monthly basis for consult-
ing with the NP (e.g., Ontario) or with a fee code for complex chronic disease
management consultation whereby the physician receives a set annual fee per
complex patient to cover consultation time with the NP (e.g., BC); and (3) concern
about additional cost to the funder if both the NP and physician see the patient
during the same visit. This tends to happen for a small proportion of patients who
are receiving complementary rather than a duplication of care in much the same
way as occurs when a family physician and specialist see the same patient.
NP-Led Clinics
The Ontario Ministry of Health and Long-Term Care (MoHLTC) is funding 26
NP-led clinics. The clinics are described as a new model of care in which NPs work
in collaboration with physicians and other members of an interprofessional team
to provide comprehensive, accessible, coordinated family healthcare service to a
defined population in areas where there are high numbers of patients who do not
have a regular primary healthcare provider (Ontario MoHLTC 2010a). In addi-
tion to the provision of direct healthcare services, NP-led clinics focus on chronic
disease management and disease prevention activities. A distinction of NP-led clin-
ics when compared to other primary healthcare delivery models in Ontario such as
CHCs and family health teams (FHTs) is that the ratio of physicians to NPs is lower
and physicians function in more of a consulting than a primary provider role.
General Description of This Model
The specific activities of the NP-led clinic are to (1) provide comprehensive family
healthcare services through an inter-professional team of NPs, registered nurses
(RNs), family physicians and a range of other healthcare providers (e.g., dietitians,
mental health workers, social workers, pharmacists and health educators),
(2) provide system navigation and care coordination by linking patients to other
parts of the healthcare system (e.g., acute care, long-term care, public health,
mental health, addictions, and community programs and services), (3) empha-
size health promotion, illness prevention, and early detection and diagnosis, (4)
facilitate the development of comprehensive community-based chronic disease
management and self-care programs, (5) provide patient-centred care in which
the patient makes informed decisions about her or his self-care needs (6) link
with other healthcare organizations at the community level to address community
needs and (7) use information technology linking patient records across health-
care settings and providing timely access to test results (Ontario MoHLTC 2010a).
Key indicators for assessing the need for NP-led clinics in local areas include the
proportion of unattached patients, the prevalence of one or more of nine chronic
diseases including diabetes, the number of full-time-equivalent family physicians
in a Local Health Integrated Network (LHIN) per 10,000 population and the
number of existing FHTs and CHCs.
Interview participants involved in developing and introducing NP-led clinics
described a vision of providing primary healthcare to unattached patients in
areas with physician shortages and NP availability where NPs would work to
their full scope of practice to meet community needs. The NP-led clinics are,
by design, located in settings with physician shortages and are staffed by more
NPs than physicians in order to make the best use of available health human
resources to increase patient access to primary healthcare among those without
a regular family physician. To optimize the use of limited physician availability,
the physicians role is primarily consultative, providing advice to NPs regarding
patient care within the NP scope of practice and seeing only patients whose needs
and care extend beyond the NP scope of practice.
In November 2006, the first NP-led clinic, in Sudbury, Ontario, was approved and
became operational in August 2007. Between February 2009 and August 2010, 25
more NP-led clinics were approved, with all expected to be operational by 2012
(Ontario MoHLTC 2010b).
In Sudbury, 30,000 residents did not have a regular family physician at the time
of application for the clinic. The clinic has six NPs, two part-time collaborating
physicians, an RN, a pharmacist, an administrator and clerical staff. A full-time
social worker and dietician will soon join the interprofessional team (Heale and
Butcher 2010). The clinic operates fully out of two locations (Sudbury and Lively)
and partially in Chapleau, where well-women care is provided one out of every six
weeks. It is expected that each full-time-equivalent NP will build a roster of 800
patients. All patients are registered to the clinic and see their NP for the majority
of their healthcare needs. Because patients are registered with the clinic and not
rostered to an individual NP, however, they remain patients of the clinic regardless
of staffing changes. Physicians are part of the team and available on-site a total of
five half days per week to consult about more complex care issues. They receive
monthly collaboration fees and can bill FFS for direct patient encounters in cases
that go beyond the scope of NP practice.
The clinic has an NP-led governance model with a not-for-profit board, 51%
of which must be made up of NPs and 49% from the community. No board
members can be employees of the clinic. The board ensures that the clinic policies
enable the NP to work to full scope of practice and promote an inter-professional
model of care. The clinic director, who is an ex officio member, reports to the
board. This director role is purposefully filled by an NP who is responsible for
creating the supports to enable the full implementation of the NP role (e.g., clini-
cal policy for care of patients with diabetes) (Heale and Butcher 2010).
A patient satisfaction survey conducted in 2008 by the clinic board indicated high
levels of patient satisfaction, with open-ended responses highlighting thorough-
ness, quality of NP care, adequate time spent with patients and a caring attitude.
Two areas for improvement were identified: increased accessibility through
expanded hours into the evening and increased physician on-site availability
to better facilitate care when the NP must consult with the physician (Sudbury
District Nurse Practitioner Clinics Board of Directors 2008). One of the physi-
cians linked with the NP-led clinic states: I think that patients are getting excellent
care. Its like having two primary caregivers at one number. You cant beat that.
(Peters 2008: 69). An evaluation of this first NP-led clinic was commissioned by the
MoHLTC, and although completed in 2009, the report has not yet been released.
Facilitators to Establishing and Sustaining This Model
The establishment of the first NP-led clinic was facilitated by the following factors:
a large number of unattached patients in the community, a shortage of physicians,
availability of NPs to work to full scope of practice in delivering primary health-
care, a substantial amount of local media coverage that increased community
awareness about the NP role, a good working relationship with consulting physi-
cians who provide advice to NPs on patient care when needed and see patients
with care needs beyond the NP scope of practice, high patient satisfaction, and
an NP-led governance structure to support the vision and mission of the clinic.
Because previous experience had indicated that working for administrative leads
who did not fully understand the NP role led to underutilization of their skill set,
it was important to the NPs that the clinic director role be filled by an NP.
Challenges to Establishing and Sustaining This Model
When the NP-led clinic opened its doors in August 2007, the majority of patients
seeking care were those with highly complex needs that had not been addressed
for some time due to the physician shortage. Assessment and treatment decisions
for patients with these multi-faceted care needs entailed lengthy visits with the NP
and frequent physician involvement. This complexity of patient care needs associ-
ated with longer patient visits meant that the number of patients seen during the
first year of operation was not as high as expected.
Another challenge has been opposition by organized medicine. The NP-led
clinic arose out of direct lobbying of the government by the Registered Nurses
Association of Ontario and a group of local NPs in Sudbury. It is the only organi-
zational model that has been introduced in the last decade that has not been a
product of negotiations between the Ontario Medical Association (OMA) and
the Ministry of Health and Long-Term Care (Hutchison in press). The OMA has
objected to the governments intention to expand NP-led clinics because they view
the NPs as functioning independently rather than in a collaborative care model
(Strasberg 2009). Lagu (2008) notes that NP-run clinics are opening without
physicians. This is the first step on a slippery slope at the bottom of which NPs
become, essentially, substitutes for family physicians (Lagu 2008: 1668). These
concerns fail to acknowledge that the clinics are based on a collaborative model
that includes physicians and other members of the healthcare team. The misper-
ception may be partially attributable to the title NP-led, which may connote
independent NP practice rather than an inter-professional collaborative model.
An interview participant states,
I think, though, with the name nurse practitionerled clinic, there have
been some misunderstandings that that is nurse practitioner solo practice,
which it is not. The vision for that is to evolve into a fully inter-professional
model, the difference being that it is led by nurse practitioners. And so
those goals of being able to offer interprofessional care through a nurse
practitionerled model have not yet been realized.
Strengths of This Model
The NP-led clinic is a new model of care introduced in Ontario in 2007, and
as with the integration of NPs into FFS primary healthcare practices, very little
research has been conducted to date to fully explore its merits and limitations.
Early experience with the first fully operational clinic indicates that (1) in settings
with physician shortages and where patients do not have a regular family physi-
cian, NPs working to their full scope of practice can increase patient access to care
and reduce the number of unattached patients (as of July 1, 2010, the Sudbury
clinic had enrolled 3,100 patients, with more new patients enrolling weekly),
(2) efficient utilization of scarce physician resources can be facilitated by using
physician time to provide consultative services to NPs regarding patient care
within the NP scope of practice and to see only those patients whose needs and
care extend beyond the NP scope of practice, (3) the model of care enables an
inter-professional team approach that includes NPs, physicians, an RN, phar-
macist, social worker and dietician, (4) a governing board that includes NPs and
community members, none of whom are employed by the clinic, supports the
vision and mission of the clinic, (5) patients are registered with the clinic rather
than with an individual NP and therefore remain patients of the clinic regardless
of staffing changes and (6) based on preliminary evaluation data, patients and
providers are satisfied with the clinic services.
Limitations of This Model
Limitations of this model relate to clinic and physician funding. With respect to
the first fully operational clinic, (1) there is currently no government funding to
increase accessibility through expanded hours into the evening as requested by
patients in the patient satisfaction survey, or to provide 24/7 on-call service,
(2) the limited amount of consultation funds to compensate physician time
when not directly seeing patients constrains their ability to function fully as
team members because, for example, they do not receive compensation for time-
consuming tasks such as developing medical directives or attending team meet-
ings, and (3) because the patients seen by the physicians have very complex needs,
the physicians can see only four patients every hour (with each booked for 15
minutes), which limits their FFS billings.
Discussion
Canada lags behind other Commonwealth countries in providing timely
access to high-quality primary healthcare (Schoen et al. 2007, 2009).
Innovative models are required to address this problem. In this paper,
we have described two examples of novel approaches to NP deployment
designed to increase patient access to care, the first being integration of NPs
into FFS practices and the second, the NP-led clinic. Our aim was to provide
a descriptive analysis of their development and early experiences to date. We
recognize that there is very little research about these models of care and that
our analysis is based predominantly on information derived from Internet
searches and conversations with only seven participants associated with
these models. However, this paper provides foundational knowledge that
might provide the context for future research.
Preliminary data indicate that both models are increasing patient access;
for example, an FFS physician in BC notes that the addition of the NP has
increased the practice capacity from 1,200 to 1,800 patients. As of July 1,
2010, the NP-led clinic in Sudbury had enrolled 3,100 patients, with more
new patients enrolled every week. While they continue to aim for a target of
4,500 patients, enrolment has been slower than expected for three reasons:
(1) the first patients who presented to the clinic were those with highly
complex care needs that had not been addressed for some time due to the
physician shortage; these patients required more time on the part of the NPs
and more physician involvement, thereby reducing the speed at which new
patients could be enrolled; (2) lack of sufficient funding for physician remu-
neration to increase their availability for NP consultations; and (3) space
restrictions the clinicians share examination rooms, limiting the number
of patients who can be seen at any one time.
There is movement under way to evaluate these models of care. Initial
informal assessments of patient and provider satisfaction are promising.
Consistently positive evaluation results for these models could increase
support for a creative mosaic of primary healthcare models tailored to
meet the needs of their regions or populations. Still, there is a need for
further research to identify their impact on patient access, the right mix of
professionals for the patients they serve, how much and how well profes-
sionals truly collaborate with one another, interventions that are effective in
improving team collaboration, and the costs and benefits of team-based care.
While team-based care may be more expensive, the increased emphasis on
health promotion and chronic disease management that teams provide may
result in reduced health resource utilization such as costly hospitalizations
over the long term (Health Council of Canada 2009).
In both models, the NPs have strong support from their collaborating physi-
cians. Patient surveys conducted in both models indicate high levels of
satisfaction with care. A challenge common to both models is the need to
increase patient and provider awareness of the NP role.
Integration of the NP into FFS practices is consistent with a more tradi-
tional model in which the physician initiates the request to add an NP to
his or her team and for the most part, leads the team. The NP-led clinic
is a unique model that challenges traditional ways of delivering primary
healthcare, and these differences have resulted in opposition from organized
medicine. This opposition, while not yet studied empirically, could be due
to a number of reasons. One could be the NPphysician ratio. Unlike most
NPphysician collaborative models, with the exception of outpost settings in
northern Canada, the NP-led clinic staffing consists of more NPs than physi-
cians (six full-time NPs and two part-time physicians). Physicians play more
of a consultative role, seeing only the patients with complex problems.
Another reason for this opposition may relate to leadership. Unlike most
NPphysician collaborative models, NPs lead the team, form the clinic as
a non-profit organization, create a board and receive government funding
(Peters 2008). While the NP-led clinic is inter-professional, it does challenge
this traditional hierarchical relationship (albeit replacing it with another
hierarchy). This may contribute to physician resistance at the organizational
level (Evans et al. 1999). The Family and General Practice section of the
OMA, for example, has challenged the provincial government plans to fund
NP-led clinics, stating that only doctors should be the ones leading teams of
other healthcare professionals, not nurse practitioners (The Canadian Press
2009). However, Hutchison notes:
The move toward collaborative and team-based approaches to care
requires a culture shift that will be especially challenging for physi-
cians who are accustomed to being the undisputed team leader. In
an interprofessional environment, involvement of other professional
and administrative staff in policy and management decisions is no
longer discretionary (2008: 1314).
A third reason for the opposition may relate to the misperception that NPs
are working independently, and this may result from the ill-conceived term
NP-led to describe the clinic. NP-led was not intended to connote inde-
pendent practice, but rather a model of inter-professional primary healthcare
delivery in which NPs play a major role in its governance and senior manage-
ment. NPs provide the majority of care to previously unattached registered
clients and consult with other healthcare team members as necessary (Heale
and Butcher 2010). Tensions increase when words such as autonomous and
independent are used to describe NP practice. As autonomous practition-
ers, NPs are registered to practise in an expanded/extended role, and they are
liable for their own practice. NPs who function independently are those who
set up their own practice and work as solo practitioners. While this model
exists in the United States, it is rare in Canada.
Health human resource issues, funding constraints, patient access challenges,
increased emphasis on chronic disease management, primary healthcare
reform, and an aging population have prompted significant transformations
to the healthcare division of labour. Most professions are having to adapt as
boundaries between professional jurisdictions are continually renegotiated.
Physicians may feel threatened by NPs; NPs in turn may feel threatened by
physician assistants (PAs); RNs may feel threatened by registered practical
nurses (RPNs), and all struggle for clear identities (Beaulieu et al. 2008). This
engenders understandable fears related to loss of autonomy and control and
leads to resistance. Interestingly, however, at the front-line in primary health-
care most physicians, NPs, healthcare team members and patients report
high levels of satisfaction with team-based care (Barrett et al. 2007).
Baerlocher and Detsky (2009) describe turf battles between and within
professions when competing to perform the same task. They explain that
reliance on self-governing professional bodies to determine appropri-
ate work boundaries is problematic as these bodies may have no reason to
cooperate with one another. The authors further note that solving work-
force problems requires successful negotiation that keeps the publics rather
than the professions interest in mind. As a result of this tension between
professions, we lack a common vision that allows all practitioners to work
to their full scope of practice in primary healthcare delivery. Hutchison has
suggested that the government establish a mechanism to bring together both
physician and non-physician primary healthcare providers to advise on
primary healthcare policy development and implementation. He states that
Acknowledgements
their busy schedules to participate in key informant interviews and focus groups
and the seven additional individuals including NPs, physicians, and managers
who provided background and descriptive information and commented upon the
presentation of the models described in this paper. The following staff members
provided excellent support: Heather Baxter, Renee Charbonneau-Smith, R. James
McKinlay, Dianna Pasic, Julie Vohra, Rose Vonau, and Brandi Wasyluk. Special
thanks go to our advisory board, roundtable participants and Dr. Brian Hutchison
for their thoughtful feedback and suggestions.
rather than dealing with policy makers through separate, private bilateral
discussions, stakeholders would be obliged to hear each others perspec-
tives and would be under pressure to serve the public good by constructively
addressing areas of conflicting interest (In press).
In her paper about the future of the NP role, Pogue (2007) notes that NPs
can serve as a disruptive innovation, as described by Uhlig (2006), by being
catalysts for healthcare transformation. The models of care described in this
paper have provided an impetus for engaging healthcare providers in discus-
sions about how to best utilize all members of the inter-professional team to
increase patient access to high-quality primary healthcare.
Historically, NPs have been introduced at times when patient access to care
is limited, beginning in the late 1960s in northern Canada, followed by the
early 1970s in primary healthcare settings in urban Canada, and continu-
ing with the development of the acute care NP role in specialty areas such
as neonatology, cardiology and neurology. An abundant amount of high-
quality research has consistently demonstrated NPs effectiveness and safety
(Horrocks et al. 2002). The models described in this paper are promising
practices that if implemented more broadly could address patient needs
through improved access to care.
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This special issue was funded by the Canadian Health Services
Research Foundation, Health Canada and the Knowledge Translation
Branch of the Canadian Institutes of Health Research (FRN 109189)
Canadian Institutes
of Health Research
Instituts de recherche
en sant du Canada
Canadian Institutes
of Health Research
en sant du Canada
This special issue was funded by the Canadian Health Services
Research Foundation, Health Canada and the Knowledge Translation
Branch of the Canadian Institutes of Health Research (FRN 109189)
Canadian Institutes
of Health Research
en sant du Canada
Canadian Institutes
of Health Research
en sant du Canada

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