Starting Somewhere: Advanced Practice Nursing in Canada

Abstract

Many countries are capitalizing on nurses with advanced degrees or practice experience to increase patients’ access to healthcare. In Canada, there are two advanced practice nursing roles – nurse practitioners (NPs) and clinical nurse specialists (CNS). While both NPs and CNSs are knowledgeable nursing leaders who make important contributions to the healthcare system, only NPs have a protected title and are separately licensed from registered nurses (RNs). In this chapter, the author explores how entry-level-competencies (ELCs) are essential to the separate licensure of NPs. The author also argues how ELCs may increase NPs’ role recognition and effective use in the Canadian healthcare system.

1. Introduction

“If you don’t start somewhere, you’re going to go nowhere.” – Bob Marley.

Globally, registered nurses (RNs) with advanced degrees or specialized qualifications often take on important clinical leadership and advanced practice roles, which can increase patients’ access to quality healthcare [1]. However, the context and implementation of these roles varies between countries, with some countries showing slower acceptance and/or implementation than others [1, 2]. In one study, Jean et al. [2] explored advanced nursing roles in Canada and Spain, and found that, while both countries needed these roles, each country was at a different implementation stage. Similar barriers to implementation were found in both countries, including lack of role clarity, opposition from other health professionals (e.g., concerns about ‘scope creep’ or the scope of practice expansion of one health profession through legislation into the scope of practice of another), education/training issues, and regulatory concerns [2]. These findings are similar to those of other researchers [3, 4].

Entry-level competencies (ELCs), written collaboratively by advanced practice nurses, regulatory bodies and other stakeholders, including other health professionals and patients, increase the role clarity and integration of one advanced practice nursing role, that of the nurse practitioner (NP), into the healthcare system [5]. These statements describe the abilities/knowledge/judgment entry-level practitioners need to provide safe care [6, 7]. ELCs provide the ‘somewhere’ to start for other advanced practice nurses seeking to better define and promote their roles and receive greater recognition for their contributions to quality patient care.

2. Canada’s advanced practice nursing and nurse practitioners

The ICN [1] uses the term ‘advanced practice nurse’ to describe “a generalist or specialist nurse who has acquired, through additional graduate education (minimum of a master’s degree), the expert knowledge base, complex decision-making skills and clinical competencies” for an expanded role in patient care (p. 6). In Canada, advanced practice nursing began in the 1890s with outpost nurses who worked in isolated, rural, and northern areas [8]. Over the years, Canadian advanced practice nursing has evolved, and today, there are two widely recognized advanced practice nursing roles – NPs and clinical nurse specialists (CNS) [9]. While NPs and CNSs are both knowledgeable nursing leaders who contribute significantly to patients’ care, only NPs have a protected title and are separately licensed from RNs [10]. The first NPs in Canada appeared in the 1960s and were viewed as a solution to physician shortages, and a way to increase patients’ access to primary healthcare and lower costs [11]. By 1972, a national report (the Boudreau report) recommended the implementation of NPs to meet Canadian primary healthcare needs [8]. The recommendations were not followed, and the Canada-wide implementation of NPs has remained inconsistent [12, 13].

There is strong evidence supporting NPs’ effectiveness as care providers in a variety of settings. Stanik-Hutt et al. [14] reviewed 37 articles published between 1990 and 2009 and determined that NP-provided care was on par with physician-provided care in primary care clinics. Kleinpell et al. [15] reviewed 53 articles between 2008 and 2018 and concluded that the evidence supported the inclusion of NPs in the care of acute and even critically ill patients. Despite the number of studies illustrating the value of NPs as care providers, the implementation of the role Canada-wide has been variable [13]. The role is most widely implemented in Ontario [16]. In 2021, there were 7400 active NP licenses in Canada, with over half practicing in Ontario [16].

3. Barriers to implementation

Several studies have identified barriers or factors that impede the implantation of the NP role across Canada [17, 18, 19, 20, 21]. The most common barrier noted in these studies relates to role clarity. For example, Kilpatrick et al. [18], who evaluated the integration of NPs into a cardiology healthcare team in Quebec, found NPs struggled to practice to their full scope due to unclear role definition. They noted that this may also have contributed to tension between NPs and other team members, particularly physicians [18]. As Rickards and Hamilton [19] note, a lack of role clarity can lead to confusion among patients and other team members, hindering collaboration and effective implementation of the role. Role confusion is understandable. In Canada, NPs’ roles are determined by both their legal and individual scopes of practice. The legal NP scope of practice (i.e., what NPs are authorized to do) is defined through provincial legislation (i.e., nursing acts), with NP roles expanding in many provinces over the years [9]. In Ontario, for example, NP’s authority to prescribe prior to 2010 was restricted to a pre-approved list of drugs or renewing drugs first prescribed by physicians [22]. Since then, their prescribing privileges have expanded to more classes of drugs, including controlled drugs/substances [22]. Today, all provinces and territories have NP legislation in place [9]. Although there is some variation, generally, NPs can autonomously diagnose/treat diseases, order/interpret tests, prescribe medications, and perform procedures [9].

Individual NPs’ scopes of practice may differ from their legal scopes of practice; and may be influenced by many factors, particularly their clinical competence [23]. For example, Medical Assistance in Dying (MAiD) was legalized in Canada in 2016 [24]. In most provinces, NPs are authorized to prescribe substances that cause death for eligible patients [25]. In these provinces, however, each NP must determine their clinical competency to participate in MAiD [24]. If an NP does not feel competent to participate, they may develop this through additional education/clinical experience. The concept of clinical competence is difficult to define [26]. Benner [27] defines clinical competence as the ability to perform a task to a desirable outcome under certain circumstances within a clinical context. Other authors argue that this concept needs to be considered more holistically [28, 29]. For example, Nabizadeh-Gharghozar et al. [28] explain clinical competence as “the combination of knowledge, skills, attitude and ability” which are used to provide safe patient care without supervision (p. 2). NPs’ competence can be visualized as a balloon that expands and changes shape throughout their careers as they gain clinical experience and the context of their practice changes [5].

4. Enablers to implementation

Some studies have identified enablers or factors that facilitate the implementation of the NP role. Unsurprisingly, a scoping review by Torrens et al. [21], found that role clarity and a positive attitude by other healthcare professionals toward the clinical competency of NPs promote role implementation. Similarly, Brault et al. [30] found it was essential to clarify roles when NPs joined primary care teams to mitigate power struggles, facilitate integration, and foster intra/interprofessional collaboration.

One effort by NP-advocates and supporters to clarify the NP role was the development of ELCs for NPs. In 2012, the Canadian Council of Registered Nurse Regulators (CCRNR) began a project to establish national ELCs to standardize NP practice and improve NP mobility [6]. The resulting ELCs were organized into four categories: (1) patient care, (2) quality improvement and research, 3) leadership, and 4) education, and were adopted, with some adaptions, by nearly all provincial/territorial regulatory bodies [31]. Each of the categories is supported by specifically written statements, which describe the minimum expected levels of performance required for newly graduated NPs to practice safely in a variety of settings [7, 31]. The ELCs articulate, using standardized language, NPs’ role and how their practice differs from that of other nursing professionals, such as RNs [6]. Notably, the ELCs are not static and are revised/modified to respond to current issues, needs, and trends in NP practice, such as increasing concerns about mental health and problematic substance use [31] or the recommendations from the Truth and Reconciliation Commission of Canada [32].

The ELCs increase the standardization of NP education, which is also essential for role clarity and development [33]. As Bryant Lukosius et al. [33] argue, the standardization of NP education is needed to achieve consistency and ensure curriculums align with current and expanding NP scopes of practice. In countries like Canada, where generalized nursing education is at the baccalaureate level, NPs currently require a masters degree from an accredited program. This was not always the case, as a 2010 environmental scan by the Canadian Association of Schools of Nursing [34] found that only 75% of the 27 NP programs in Canada were at the masters level. The ELCs are both a guide for curriculum development and a way for accrediting and regulatory bodies to assess NP education programs [35]. Increased standardization means that NP educators must prove to accreditors/regulators how they prepare their students to meet the ELCs [36]. Consequently, many NP educators use curriculum mapping to provide evidence that their curriculum/courses demonstrate alignment. The ELCs also inform the development and revision of the Canadian Nurse Practitioner Examination [35]. Thus, they are an essential link between formal educational programs (like master’s programs) and licensing bodies (i.e., the provincial/territorial nursing regulatory bodies).

The ELCs guide both curriculum development in NP programs and entry-level exam test plans and so are critical to the NP licensure process [35]. Provincial/territorial legislation allows nursing regulatory bodies to protect the public by setting NP licensure requirements and ensuring all NPs practice at an acceptable level [37]. The NP licensure process is similar in most provinces and territories, and involves an assessment of applicants’ experience, education, and competence [38]. Specifically, applicants need to prove they (1) were previously registered as an RN, (2) completed an NP educational program, and (3) passed the Canadian Nurse Practitioners Examination [38]. Licensing assures patients that they are treated by qualified professionals who will provide a safe standard of care.

5. Clinical nurse specialists

NPs are often confused with CNSs, the other widely recognized advanced practice nursing role [10]. Although there are similarities between the two, such as requiring advanced degrees and/or qualifications, there are important differences [33]. As Bryant-Lukosius et al. [33] emphasizes, NPs usually provide more direct patient care, while CNSs support excellence in clinical practice. The CNS title is not protected. Also, only NPs must meet ELCs specific to their role and are licensed separately from RNs [10]. Arguably, the implementation of CNSs in Canada has been even more inconsistent than NPs [10]. As Bryan-Lukosius et al. [33] notes, “the profile and deployment of CNS roles… have fluctuated … and the full benefit of the role has yet to be realized” (p. 140). Several studies reported role confusion and role overlap with NPs as barriers [39]. Some CNS-advocates argue that ELCs specific to the CNS role may help with its advancement and the standardization of CNS education [8, 40]. However, opponents argue that ELCs are unnecessary because CNSs do not write a different licensing examination and have separate licenses from RNs [40]. These opponents also worry ELCs may not capture the multifaceted aspects of this role, which is perceived as more varied than the NP role, with more involvement supporting other healthcare providers and leading evidence-based practice, quality assurance and program development activities [40, 41].

In 2014, CNA published the “Pan-Canadian Core Competencies for the Clinical Nurse Specialist” to clarify the role. In the future, there may be separate ELCs, which describe the minimum expected levels of performance required for all CNSs new in their roles. ELCs may be ‘somewhere’ to start for those looking to further standardize CNS education (e.g., a specialized masters degree or certificate/diploma program), develop CNS certification exams (similar to those in the United States), or set up other special credentialing [40]. If CNS-advocates advance the role in any of these directions, ELCs will be a needed starting point.

6. Directions for the future

The CCRNR [35] is updating the national NP ELCs, which will guide the development of a new entry-to-practice exam. This will further increase the standardization and quality of Canadian NP educational programs. The COVID-19 pandemic showed the multiple vulnerabilities of the healthcare system and the vital role NPs can play [42]. The number of NPs grew by 10.7% between 2020 and 2021 [16]. Although the future looks bright, a shortage of qualified nurse academics may limit future student enrollments [43]. Canada, like many countries, is plagued by a recurrent nursing faculty shortage [34]. As CASN [34] report found, Canadian nursing schools could not fill 46 faculty positions, representing a 2% vacancy rate. To fully implement the NP role, qualified nursing academics are needed to educate the next generation. Future research is needed to address the factors contributing to the nursing academic workforce shortage and to develop innovative strategies to promote faculty recruitment and retention [43].

7. Conclusion

In Canada, implementation of the NP role has yet to be fully realized, primarily due to role confusion. This confusion has led to less awareness about the role, which has made healthcare regulators slow to take advantage of these skilled professionals. The establishment of national ELCs provides a means to articulate the role of newly graduated NPs and to ensure acceptance of their role by other health professionals and the patient community. The ELCs increase the standardization/quality of NP educational programs, guide curriculum development, are a way for accrediting and regulatory bodies to assess NP education programs and inform the development and revision of the entry-to-practice exam. Consequently, they are an essential link between formal educational programs (like masters programs) and licensing bodies (i.e., the provincial/territorial nursing regulatory bodies). CNS-advocates who want to advance the role through more standardized education or other special credentialing may want to develop similar ELCs as ‘somewhere’ to start.