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aduate Course Syllabus
DV NCED NURSING PR CTICE
: Paced/home-stdy!lectre! discssio"
: # c$
:
rse Coordi"ator : Nrsalam
dents review the characteristics and competencies of advanced nursing practice and examine issues related to theelopment of the role of an advanced practice nurse. Students build on their understanding of the competencies of advanced
sing practice to develop a vision of a future role in advanced nursing practice. As well, students develop a funding proposal
a project related to advanced nursing practice. Finally, students consider various futures scenarios that may shape theiranced nursing practice.
ter completing this course, students should be able to:
1. Discuss the characteristics and competencies of advanced nursing practice!. "valuate application of the competencies of advanced nursing practice in their own practice
#. Discuss issues related to implementation of advanced nursing practice roles, in particular the role of the nurse
practitioner
$. Develop awareness of how advanced nursing practice %particularly the role of the nurse practitioner& is regulated inhis'her province'territory
(. Analy)e current issues influencing advanced nursing practice, with particular reference to the role of the nurse
practitioner*. "xplore various future scenarios for advanced nursing practice
+. rovide evidence-based clinical services to well clients of all ages and to those presenting with acute and chronic health
concerns, at a level appropriate to a beginning practitioner, includinga. health history and physical examination
b. clinical decision ma/ing
c. ordering of laboratory and diagnostic tests
d. prescription of medications
e. therapeutic communication
f. collaborative relationships
0. efer, to other health professionals, clients with health concerns that exceed the scope of practice of a beginningpractitioner offering clinical services
2. Demonstrate integration of medical and nursing management of health concerns of clients
s course consists of the following units
it 1 - Competencies of Advanced Nursing Practice I
his unit students review the characteristics of advanced nursing practice as identified by the 5anadian 6urses Association
consider the extent to which they are able to evidence these. Students then study the competencies of advanced nursingctice, reflecting on how the Advanced 6ursing ractice program has prepared them in these areas. 4t should be focused on
evelop multiple advanced assessment and intervention strategies within a
nt-centered framewor/ for individual clients, communities and populations
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se 9ualitative and 9uantitative data from multiple sources, often in ambiguous and complex situations, when ma/ingnical decisions and initiating and
naging change
naly)e the complex interaction of sociological, psychological and physiological processes, determinants of health andnts: lived experience
cipate and explain the wide range of client responses to actual or potential health problems and recommend action
it 2 - Competencies of Advanced Nursing Practice 2
his unit students review the characteristics of advanced nursing practice as identified by the 5anadian 6urses Association
consider the extent to which they are able to evidence these. Students then study the competencies of advanced nursing
ctice, reflecting on how the Advanced 6ursing ractice program has prepared them in these areas. 4t should be focused onuide decision-ma/ing in complex clinical situations
ngage clients and other team members in resolving issues at the individual, organi)ational and health-care system levels
entify and assess trends or patterns that have health implications for individuals, families, groups or communities
it - Competencies of Advanced Nursing Practice
his unit students review the characteristics of advanced nursing practice as identified by the 5anadian 6urses Associationconsider the extent to which they are able to evidence these. Students then study the competencies of advanced nursing
ctice, reflecting on how the Advanced 6ursing ractice program has prepared them in these areas. 4t should be focused on
enerate and incorporate new nursing /nowledge and develop new standards of care, programs and policies
an, initiate, coordinate and conduct educational programs based on needs, priorities and organi)ational resources andanage a wide range of patient responses to actual and potential health problems.
it ! - Advanced Nursing Practice "ole Implementation 1
his unit students study issues related to implementation of advanced nursing practice, including phases of role development,ministrative support for advanced nursing practice, and evaluation of advanced nursing practice. 4ssues related to
repreneurial opportunities and regulation of practice are explored. 3he unit closes with a loo/ at issues that may influence
future of advanced nursing practice.
it # - Advanced Nursing Practice "ole Implementation 2
his unit students study issues related to legal practice certainty from the government. 4ssues related to Nursing $ill %raft
explored. 3he unit closes with a loo/ at issues that may influence the future of advanced nursing practice.
it & - "esearc' in Advanced Nursing Practicesearch s/ills are an integral competency of advanced nursing practice and advanced practice nurses will be expected toically review research and utili)e research findings. As well, it is li/ely that advanced practice nurses will be expected tontify the need for and facilitate the development of research-based projects in their wor/ settings.
it ( ) *ealt' "esearc' +et'ods
oduction to the scientific method, experimental, 9uasi-experimental, descriptive and epidemiological research.
asurement issues 9uestionnaire development, reliability and validity of data, issues of sampling and sample si)e. "thicsesearch. Descriptive statistics, estimation and confidence intervals, inferential statistical tests. 8se of SSS statistical
tware. "lements of critical appraisal.
it , - Clinical Practicum and Community Assessment Processes and "e.uirements
s unit reviews the re9uirements of the clinical practicum and community assessment. 3he focus of the clinical practicumcommunity assessment of this course is =closure.= Students end their student relationship with their preceptors and with
mbers of the community with whom they have developed relationships during your community assessment.
it / - Advanced Nursing Practice Compre'ensive 0amination
ring this course students are re9uired to complete a comprehensive examination. 3he examination evaluates /nowledge inh the clinical services and community health development components of advanced nursing practice. Students must pass the
mprehensive examination in order to graduate from the Advanced 6ursing ractice program. 3his unit provides information
ut the examination and suggestions to assist students in preparing for the examination.
it 1 ) Clinical 3eaders'ip
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e unit consists of clinical leadership approaches'theories, decision ma/ing team building reflective practice, managingflict facilitating change and creating empowered wor/ environments. 3hese topics will be explored in the context of the
temporary healthcare environment and viewed from an ethico-legal stance. 4ncluded will be /nowledge of contemporary
ues in health care and trends in the development of effective clinical leadership in professional practice.
it 11 ) %evelopmental *ealt'
rrent research-based evidence on developmental and population health. 4nteraction of ecological, biological, psychological
social determinants. Developmental lifespan, including neurobiological, cognitive, social, emotional and moral
elopment. >io-psycho-social and cultural aspects utilising appropriate research findings and conceptual framewor/s to
ess, plan, implement and evaluate interventions targeting individuals, families and communities.
it 12 ) *ealt' Pro4ect Preparation
velopment of an investigation into an individual area of speciality. Development of a critical review of related literature,
dy design and methodology for the proposal in consultation with the project supervisor. reparation of a project'researchposal.
it 1 - Pro4ect %evelopment in Advanced Nursing Practice
his unit students learn how to develop project proposals.
it 1! - Preparation for Advanced Nursing Practice
his unit students consider possible futures of advanced nursing practice, including both components of extended healthvices and community health development.
ference
Affara F ? Schober lac/well
Association of egistered 6urses of 6ewfoundland and abrador. %!@@+&. Advanced practice-clinical nurse specialist
Bosition statementC. St. ohn:s Author.
De;rasse, 5., ? 6ic/lin, E. %!@@1&. Advanced nursing practice ld hat, new design. 5anadian ournal of 6ursing
eadership, 1$%$&, +-1!.
Furlong, "., ? Smith, . %!@@(&. Advanced nursing practice olicy, education and role development. ournal o
5linical 6ursing, 1$, 1@(2-1@**.
Gamric, A., Spross, ., ? Ganson, 5. %!@@2&.Advanced nursing practice: An integrative approach%$th ed.&. St. ouis"lsevier Saunders.
>ryant-u/osius, D., ? Di5enso, A. %!@@$&. A framewor/ for the introduction and evaluation of advanced practice
nursing roles. ournal of Advanced 6ursing, $0%(&, (#@-($@.
>ryant-u/osius, D., Di5enso, A., >rowne, ;., ? inelli, . %!@@$&. Advanced practice nursing roles Development,
implementation and evaluation. ournal of Advanced 6ursing, $0%(&, (12-(!2.
3extboo/s and readings from other Advanced 6ursing ractice courses will be used as appropriate.
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Advanced Nursing Practice
A National Framework
2008
www.cna-aiic .ca
http://www.cna/http://www.cna/7/26/2019 ANP Role Peraturan Nursalam 11
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This document has been prepared by CNA in the pursuit of
CNAs mission, vision and goals. It has been approved by theCNA Board of Directors.
All rights reserved. ermission to photocopy or do!nload for individual use is granted.
"urther reproduction in any manner, including posting to a!ebsite, is prohibited !ithout prior !rittenpermission of the publisher. ermission may be obtainedby contacting CNA at permissions#cna$aiic.ca.
% Canadian Nurses Association
&' Drive!ay(tta!a, (N )* +*
Tel.- +/$*/0$*+// or +$1''$/+$12'2"a3- +/$*/0$/&*'!!!.cna$aiic.ca
"ebruary *''1
I4BN 501$+$&&++5$ *+*$/
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Contents
Introduction . . . +
volution of Advanced Nursing ractice &
De6nition and Characteristics . . . 5
De6nition . . . +'
Characteristics . . . +'
ducational reparation +/
7oles +&
7egulation +5
Competencies . . . *+
Clinical Competencies . . . **
7esearch Competencies */8eadership Competencies *2
Consultation and Collaboration Competencies . . . *
Impact of Advanced Nursing ractice *5
4upport for Advanced Nursing ractice . . . //
8oo9ing to the "uture . . . /0
:lossary 2'
Appendi3 A- A "rame!or9 2*
Appendi3 B- The Consultation rocess 2/
Appendi3 C- ;embers of the National
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Advanced nursing practice
is an umbrella term describing an
advanced level of clinical nursing
practice that maximizes the use of
graduate educational preparation,
in-depth nursing knowledge and
expertise in meeting the health needs
of individuals, families, groups, commu-
nities and populations. t involves
anal!zing and s!nthesizing knowledge"
understanding, interpreting and appl!ing
nursing theor! and research" and devel-
oping and advancing nursing knowledge
and the profession as a whole.
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ntroduction
4ociety and its health$care needs are al!ays
evolving. As a result, health care in Canada
today faces many challenges, including rising
costs, shortages of professionals, an aging
population, the introduction of ne! technology and
di=iculties !ith access to care. The
demand for collaborative, innovative clinical
practitioners to act as leaders in health care
has never been stronger.
Advanced Nursing Practice : A National Framework 1
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4ociety and its health$care needs are al!ays evolving. As a result, health care in
Canada today faces many challenges, including rising costs,
shortages of professionals, an aging population, the introduction of
ne! technology and di=iculties !ith access to care. The demand
for collaborative, innovative clinical practitioners to act as
leaders in health care has never been stronger. Nurses in
advanced nursing practice are !ell positioned to respond to the
evolution of health care. In particular, advanced nursing practice
plays a 9ey role in meeting the health needs of Canadians, by
building nursing 9no!ledge, advancing the nursing profession
and contributing to a sustainable and e=ective health$care
system.
The Board of Directors of the Canadian Nurses Association >CNA?
approved the
9ey elements of a national frame!or9 for advanced nursing
practice in @une +555. The 6rst edition of Advanced Nursing
Practice# A National $ramework!as published in ;ay *'''. That
document de6ned advanced nursing practice, identi6ed its
characteristics and competencies,+ and described the necessary
educational preparation,
the various domains of practice and potential roles, and its
regulation. The frame$
!or9 !as deliberately broad, in part to allo! for variations among
urisdictions and in part to allo! for evolution of advanced
nursing practice roles. In ;arch *''*,
the CNA Board of Directors revised
one of
...advanced nursing practice
pla!s a ke! role in meeting the
health needs of Canadians ,
b! building nursing knowledge ,
advancing the nursing profession
and contributing to a sustainable
and e%ective health -care s!stem .
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e 9ey elements of the frame!or9 by estab$
hing a graduate
greein nursing as the
nimum educational
uirement for advanced
rsing practice.
The overall obective of this national
frame$
!or9 is to promote a common
understanding
of advanced nursing practice in
Canada and
1 Terms defined in the glossary are resented in italics on first aearance in the te!t"
2 Advanced Nursing Practice : A NationalFramework
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thereby to increase consistency in role de6nition,
curricula and competency development.
The frame!or9 has already been used
for a variety
of purposes, including developing
educational
courses, outlining concepts for
research, shaping
government position statements and
interpreting
advanced nursing practice for employers,
the public,
other health$care !or9ers and policy$
ma9ers.
In *''&, CNA organied the
Dialogue on
Advanced Nursing ractice to
bring together
n &arch ' ( ( ' , the CNA )oard of
*irectors revised one of the ke!
elements of the framework b!
establishing a graduate degree in
nursing as the minimum
educational re+uirement for
advanced nursing practice .
nursing sta9eholders $ including educators, policy$ma9ers, administrators and
representatives of nursing organiations $ to discuss !hat could
be learned from
the e3isting advanced nursing practice roles, to identify !hat
more could be done
to support the evolution of advanced nursing practice and to
identify principles
and strategies that !ould promote the introduction of other
advanced nursing
practice roles . articipants identi6ed the national frame!or9
for advanced
nursing practice as a useful guide in the continued
development of this form of
practice in Canada and recommended that it be updated
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periodically to respond
to the needs of its users and to reect changes in health$care
system environments.
The Canadian Nurse ractitioner Initiative, launched in *''2, helped
in the development of a frame!or9 for the integration and
sustainability of the nurse practitioner role in Canadas health$care
system. 7ecommendations for practice, education, legislation and
regulation, and health human resources planning !ere considered
in the current revision of the advanced nursing practice
frame!or9.
Advanced Nursing Practice : A National Framework #
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The advanced nursing practice frame!or9 contains the follo!ing 9ey elements-
E evolution of advanced nursing practice
E de6nition and characteristics
E educational preparation
E roles
E regulation
E competencies
E impact of advanced nursing practice
E support for advanced nursing practice
$ Advanced Nursing Practice : A NationalFramework
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volution of Advanced
Nursing Practice
Advanced nursing practice has emerged
over the past decades as health$care systems
and governments around the !orld have come
to recognie Fthat optimiing the nursing
contribution to health care through e3panding
their role is an e=ective strategy for improving
health servicesG >4chober H A=ara, *'', p. *?.
Advanced Nursing Practice : A National Framework %
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Nurses can choose from
a variet! of diverse and
e+uall! valuable practice
opportunities , of which
advanced nursing practice
is one .
Advanced nursing practice* has emerged over the past
decades as health$care systems and
governments around
the !orld have come to recognie Fthat
optimiing the
nursing contribution to health care through
e3panding
their role is an e=ective strategy for
improving health
servicesG >4chober H A=ara, *'', p. *?.
Despite the
common development of this realm of
nursing practice,
the understanding of !hat constitutes advanced nursing practice
varies from one country to another and even !ithin countries.
Advanced practice nurses are vie!ed as e3perts in their respective
domains, engaged in activities that e3tend beyond the narro!
application of technically comple3 procedures. In particular, advanced
nursing practice involves the sophisticated use of 9no!ledge and s9ills
>Daly H Carn!ell, *''/, p. +/?.
T!o advanced nursing practice roles are recognied in Canada today- the clinicalnurse
specialistand the nurse practitioner. These t!o roles evolved from
di=erent roots. Clinical nurse specialists 6rst emerged in the +50's
as client care gre! more comple3. Their role !as to provide clinical
guidance and leadership to nursing sta= managing comple3 care, to
improve the uality of care and to promote evidence$based practice.
Cutbac9s in the +51's and +55's led to the elimination of many of
these positions, but as concern over the uality of care builds in the
early *+st century, there is reason to believe that the clinical nurse
specialist role !ill regain prominence.
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In Canada, the origin of the nurse practitioner lies in the !or9 of
nurses !ho, decades ago,
provided care that !as other!ise unavailable in rural and remote areas.
Nurse practitioners
gained formal recognition in the +50's, !hen this role !as
recommended by policy$ma9ers
as a !ay of providing health care to isolated populations. ducation
programs !ere started,
2 Advanced nursing ractice is used &y 'NA as the um&rella term for the advanced level of clinicalractice descri&ed inthis framework( individuals in advanced nursing ractice roles are referred to in this document asadvanced ractice nurses"Nurses refers to registered nurses"
) Advanced Nursing Practice : A NationalFramework
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Canadian advanced practice nurses have
but a perceived oversupplyof
physicians, a lac9 of
enabling
legislation and problems
related
to remuneration caused
interest
to !ane. Interest !as
re9indled
in the +55's by health$
care
the education , clinical expertise , leadership
skills and understanding of organizations , health
polic! and decision -making to pla! an important
role in client and health -care s!stem outcomes now
and in the future .
reform, an increased demand for access to primary health care and
the need for integrated care. The Canadian Nurse ractitioner
Initiative !as launched in *''2 to develop a panCanadian frame!or9
to encourage full integration of nurse practitioners into Canadian
health care.
As demand, technology and 9no!ledge change the !ays in !hich
health care is delivered,
interest in advanced nursing practice is on the rise. Trends in the
delivery of health care
are providing opportunities for nurses to e3pand current roles and
create ne! ones. Nurses
can choose from a variety of diverse and eually valuable practice
opportunities, of !hich
advanced nursing practice is one. As nurses move along the continuum
of e3perience and
education, they acuire additional competencies that become
incorporated into their
practice. This evolution enables nurses to contribute to the health$care system in ne!
!ays.
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Although all nurses contribute to the health$care system through their !or9 in
clinical practice, education, administration, research and policy, advancednursing
practice focuses on the clinical domain in a !ide array of practice settings.Clinical
practice not only incorporates direct client care but also involves a supportiveand
consultative role. Canadian advanced practice nurses have the education, clinical
e3pertise, leadership s9ills and understanding of organiations, health
policy and decisionma9ing to play an important role in client and
health$care system outcomes no! and
in the future.
Advanced Nursing Practice : A National Framework *
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8 Advanced Nursing Practice : A NationalFramework
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*enition and
Characteristics
*enition
Advanced nursing practiceis an umbrella term
describing an advanced level of clinical nursing
practice that ma3imies the use of graduate educational
preparation, in$depth nursing 9no!ledge and e3pertise in
meeting the health needs of individuals, families, groups,
communities and populations.
Advanced Nursing Practice : A National Framework +
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*enition
Advanced nursing practice is an umbrella term describing an
advanced level of clinical nursing practice that ma3imies the use
of graduate educational preparation, in$depth nursing 9no!ledge
and e3pertise in meeting the health needs of individuals, families,
groups, communities and populations. It involves-
E analying and synthesiing 9no!ledge
E understanding, interpreting and applying nursing theory and research and
E developing and advancing nursing 9no!ledge and the profession as a !hole.
Characteristics
In advanced nursing practice, nurses build on their e3pertise in
a specialty area,
integrating and consistently displaying the follo!ing featuresand characteristics-
E provision of e=ective and e=icient care, delivered !ith
a high degree of autonomy, to an identi6ed population
E demonstration of leadership and initiation of change to
improve client, organiation and system outcomes
E deliberate, purposeful and integrated use of in$depthnursing 9no!ledge, research and clinical e3pertise, as
!ell as integration of 9no!ledge from other disciplines
E depth and breadth of 9no!ledge that dra!s on a !ide
range of strategies
to meet the needs of clientsand to improve access to and
uality of care
E ability to e3plain and apply the theoretical, empirical,
ethical and e3periential foundations of nursing practice
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10 Advanced Nursing Practice : A NationalFramework
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E understanding, development and dissemination of
evidence$based nursing 9no!ledge
E ability to initiate or participate in planning,
coordinating, implementing
and evaluating programs to meet client needs and
support nursing practice
E use of 9no!ledge$transfer techniues to put research$
based 9no!ledge into practice
E demonstration of advanced udgment and decision$ma9ing s9ills and
E critical analysis of and inuence on health policy.
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Advanced Nursing Practice : A National Framework 11
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12 Advanced Nursing Practice : A NationalFramework
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ducational Preparation
The minimum educational preparation for
advanced nursing practice is a graduate degree in
nursing. A nurse !ith this type of graduate
preparation has a thorough grounding in the
theoretical foundation of nursing and can
promote nursing research, generate ne!
9no!ledge and use academic preparation,
synthesis and 9no!ledge$transfer s9ills to
interpret and incorporate ne! 9no!ledge
into clinical practice.
Advanced Nursing Practice : A National Framework 1#
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The minimum educational preparation for advanced nursing practice is a graduate
degree in nursing. A nurse !ith this type of graduate preparation has a thorough
grounding in the theoretical foundation of nursing and can promote
nursing research,
generate ne! 9no!ledge and use academic preparation, synthesis
and 9no!ledge$
transfer s9ills to interpret and incorporate ne! 9no!ledge into
clinical practice.
Although a graduate degree is essential for advanced nursing
practice, nurses !ho have completed one or more graduate degrees
cannot assume that their practice is at an advanced level on the
basis of these educational credentialsalone. It is the combination of
graduate education and clinical e3perience that allo!s nurses to
develop the competencies reuired in advanced nursing practice.
8i9e all nurses, advanced practice nurses are committed to lifelong
learning. In addition to pursuing such learning for themselves, they
are committed to promoting, leading and contributing to the lifelong
learning of others.
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1$ Advanced Nursing Practice : A NationalFramework
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oles
Advanced nursing practice focuses on clinical
practice, !hether through a direct relationship
!ith clients or through a supportive and
consultative role. Nurse educators, researchers
and administrators must demonstrate compe$
tencies in advanced nursing practice and
must have clinical practice as a signi6cant part
of their role if they are to be considered as
functioning !ithin advanced nursing practice.
Advanced Nursing Practice : A National Framework 1%
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Advanced nursing practice focuses on clinical practice, !hether
through a direct relationship !ith clients or through a supportive
and consultative role. Nurse educators, researchers and
administrators must demonstrate competencies in advanced
nursing practice and must have clinical practice as a signi6cant
part of their role if they are to be considered as functioning !ithin
advanced nursing practice.
(nly t!o advanced nursing practice roles are recognied in Canada
today- the clinical nurse specialist and the nurse practitioner. These
t!o roles are fundamentally di=erent. Clinical nurse specialists
provide e3pert nursing care for specialied client populations. They
play a leading role in the development of clinical guidelines and
protocols,
promote the use of evidence, provide e3pert support and
consultation, and facilitate system change >Association of
7egistered Nurses of Ne!foundland and 8abrador,
*''0?. In contrast, nurse practitioners provide direct care
focusing on health promotion and the treatment and management
of health conditions. They are Fregistered
nurses !ith additional educational preparation and e3perience
!ho possess and
demonstrate the competencies to autonomously diagnose, order
and interpret
diagnostic tests, prescribe pharmaceuticals and perform speci6c
procedures !ithin
their legislated scope of practiceG >CNA, *''a?.
/ith a focus on health promotion and disease
prevention , both the clinical nurse specialist and the
nurse practitioner 0enhance the provision of timel! ,
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accessible , cost -e%ective and +ualit! health care for all
Canadians 1
2CNA , ' ( ( 3 b , p . 4 5 .
1) Advanced Nursing Practice : A NationalFramework
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06he clinical nurse specialist pla!s
Clinical nurse specialists and nursepractitioners
spend di=erent amounts of time providingdirect
clinical care, but both roles incorporateeducation,
research, consultation and leadershipcomponents.
Client, organiation and system needs !illhelp to
shape and determine the role of individualclinical
nurse specialists and nurse practitioners.
CNA, *''b, p. /?. It
is
anticipated that ne! advanced nursingpractice
roles !ill develop to meet the e3isting andemerging
health$care needs of Canadians. "or e3ample,several
urisdictions are e3ploring an advancednursing
practice role !ithin anesthesia care.
Advanced Nursing Practice : ANational Framework
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pivotal role in the provision of
afe , e%ective , evidence -based care , supporting nurses to ensure that
e! maximize their skills
nd abilities . 1
, -ernadine .allis/ clinical nurse secialist
.innieg/ 0anito&a
nurse practitioner complements
ther than replaces other health -
are providers , bridges the gap
service deliver! for patients , expands care options , and supports a shift
wellness -based care . 1
, 0ary Nugent/ nurse ractitioner
Ta&er/ Al&erta
1*
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18 Advanced Nursing Practice : A NationalFramework
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egulation
A frame!or9 describing advanced nursing
practice allo!s for a coordinated national
approach, permits e3ibility among provinces
and territories, and allo!s ne! roles to develop.
4uch a coordinated approach is necessary to
ensure that the public has access to consistent,
high$uality nursing services across the country.
It !ill also facilitate labour mobility for
advanced practice nurses !ho are subect to
speci6c provincial or territorial legislation.
Advanced Nursing Practice : A National Framework 1+
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A frame!or9 describing advanced nursing practice allo!s for a
coordinated national
approach, permits e3ibility among provinces and territories, and
allo!s ne! roles to develop. 4uch a coordinated approach is
necessary to ensure that the public has access to consistent, high$
uality nursing services across the country. It !ill also facilitate
labour mobility for advanced practice nurses !ho are subect to
speci6c provincial or territorial legislation.
Advanced practice nurses are registered nurses !ho are licensed by
and accountable to
the registered nursing regulatory body established by legislation in
each province and
territory. "or many advanced practice nurses, additional regulation
and standards are not
reuired because they practise !ithin the scope of registered nursing
in their respective
urisdictions. In some cases, the scope of practiceincludes
additional responsibilities,
such as prescriptive authority, that may reuire additional regulatory
authority, but these
additional authorities are all !ithin the scope of practice of nursing.
The regulation of nursing practice is intended to safeguard the
public by ensuring that nurses meet standard levels of 9no!ledge
and education. In Canada, regulatory titles, including Fregistered
nurseG and F7N,G are protected, but other titles, such as Fnurse,G
Fnurse practitionerG and FN,G may or may not be protected according
to the legislation of speci6c urisdictions.
Currently, the only advanced nursing practice
A framework describing advanced
nursing practice allows for a
coordinated national approach , permits
7exibilit! among provinces and territories , and allows
new
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roles to develop .
20
role !ith additional regulation and title protection
in Canada is the nurse practitioner,
although the speci6c title used varies
among the provinces and territories. As
ne! roles in advanced nursing
practice emerge, they may or may not reuire
additional legislation and regulation.
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Competencies
Competencies are the speci6c 9no!ledge, s9ills,
udgment and personal attributes reuired for a
registered nurse to practise safely and ethically in
a designated role and setting >CNA, *''&?. Core
competencies for advanced nursing practice are
based on an appropriate depth, breadth and range of nursing
9no!ledge, theory and research, enhanced by clinical
e3perience.
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Competencies are the speci6c 9no!ledge, s9ills, udgment and personal
attributes reuired
for a registered nurse to practise safely and ethically in a designated
role and setting
>CNA, *''&?. Core competencies for advanced nursing practice are
based on an appropriate
depth, breadth and range of nursing 9no!ledge, theory and research,
enhanced by clinical
e3perience./ They cut across specialty lines and are e3hibited by all
advanced practice nurses.
This frame!or9 separates competencies into four categories- clinical,
research, leadership,
and consultation and collaboration. Jo!ever, it is the e=ective and
simultaneous interaction,
blending and e3ecution of 9no!ledge, s9ills, udgment and personal
attributes in a !ide
variety of practice environments that characteries advanced nursing
practice.
Clinical Competencies
The cornerstone of advanced nursing practice is e3pertise in a specialized area ofnursing.
Through a holistic and integrated approach, the nurse !or9s in
partnership !ith the client and other members of the health$care team
in the provision of comprehensive care.
An advanced practice nurse integrates e3tensive clinical e3perience
!ith theory, research and in$depth nursing and related 9no!ledge to-
E develop multiple advanced assessment and intervention
strategies !ithin a
client$centred frame!or9 for individual clients,communities and populations
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E use ualitative and uantitative data from multiple sources,
often in ambiguous and comple3 situations, !hen ma9ing
clinical decisions and initiating and
managing change
E analye the comple3 interaction of sociological, psychological
and physiological processes, determinants of health and clients
lived e3perience
# 'ometencies secific to the nurse ractitioner role and resonsi&ilities are identified in 'anadian Nurse Practitioner:'ore 'ometency Framework 1'NA/ 200%"
22 Advanced Nursing Practice : A NationalFramework
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E anticipate and e3plain the !ide range of client
responses to actual or potential health problems and
recommend action
E guide decision$ma9ing in comple3 clinical situations
E engage clients and other team members in resolving issues
at the individual, organiational and health$care system
levels
E identify and assess trends or patterns that have health
implications for individuals, families, groups or
communities
E generate and incorporate ne! nursing 9no!ledge and
develop ne! standards of care, programs and policies
E plan, initiate, coordinate and conduct educational
programs based on needs, priorities and organiational
resources and
E manage a !ide range of patient responses to actual and
potential health problems.
esearch Competencies
:enerating, synthesiing and using research evidence is
central to advanced nursing practice.
An advanced practice nurse is able to-
E identify and implement research$based innovations for
improving client care, organiations or systems
E as either primary investigator or collaborator !ith other
members of the health$care team or community, identify,
conduct and support research that enhances or bene6ts
nursing practice
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Advanced practice
nurses are leaders in
the organizations and
communities where the!
work .
E evaluate current practice at individual and system levels in
light of research 6ndings
E collect data on, and evaluate the outcomes of,
advancednursing practice for clients, the nursing
profession and the
health$care system
E critiue, interpret, apply and disseminate evidence$based 6ndings and
E contribute to nursing and the health$care system by disseminating ne!
9no!ledge through formal and informal channels,
including presentationand publication at the local, regional, national and
international levels.
8eadership Competencies
Advanced practice nurses are leaders in the organiations and
communities !here they !or9. They are agents of change,
consistently see9ing e=ective ne! !ays to practise, to improve the
delivery of care, to shape their organiations, to bene6t the public
and to inuence health policy.
An advanced practice nurse demonstrates leadership by-
E advocating for individuals, families, groups and
communities in relation to treatment, the health$care systemand policy decisions that a=ect health and uality of life
E identifying the learning needs of nurses and other members
of the health$care
team and 6nding or developing programs and resources to
meet those needs
Ementoringand coaching nursing colleagues, other
members of the healthcare team, and students
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E advocating for and promoting the importance of health$
care access and advanced nursing practice to nurses and
other health professionals, the public, legislators and
policy$ma9ers
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E contributing to and advocating for an organiational
culture that supports
professional gro!th, continuous learning and collaborative
practice
E evaluating programs in the organiation and the
community and developing
innovative approaches to comple3 issues
E understanding and integrating the principles of
resource allocation and
cost$e=ectiveness in organiational and system$level
decision$ma9ing
E identifying gaps in the health$care system and developing partnerships to
facilitate and manage change
E developing and clearly articulating a vision for nursing
practice, inuencing
and contributing to the organiations and the health$care
systems vision
and implementing approaches to realie that vision
E advising clients, colleagues, the community, health$care institutions and
policy$ma9ers on issues related to nursing, health and
health care
E identifying problems and initiating change to
address challenges at the
individual, organiational or system level and
E understanding legislative and socio$political issuesthat inuence health
policy, and building strategies to improve health, health$
care access and
healthy public policy.
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Consultation and Collaboration Competencies
=ective collaboration and communication !ith clients and others on
the health$care team represent important aspects of any nursing
practice. The ability to consult and collaborate !ith colleagues
across sectors and at the organiational, provincial, national and
international level is a characteristic of nurses in advanced practice.
A nurse in advanced practice is able to-
E initiate timely and appropriate consultation, referrals and
collaboration !ith other health$care providers
E consult and collaborate !ith members of the health$care
team to develop uality$improvement and ris9$
management strategies
E !or9 !ith others to gather and synthesie ualitative
and uantitative information on determinants of health
from a variety of sources
E practise collaboratively and build e=ective coalitions
E apply theories related to group dynamics, roles and organiations
0Collaboration is a complex process re+uiring knowledge sharing
and 9oint responsibilit! for patient care ,
management and outcomes . 1
, 3andra 4uke/ nurse
ractitioner
5alifa!/ Nova
3cotia
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E demonstrate 9no!ledge and s9ill in communication,
negotiation and conict
resolution, including the ability to analye, manage and
negotiate conict
E clearly articulate the contribution of advanced nursing
practice !ithin the interprofessional health$care team
E participate in collaborative proects !ith academic
institutions and maintain cross$appointments and
E advocate for changes in health policy by participating on
regional, provincialK territorial, and federal committees that
inuence decision$ma9ing at
those levels.
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28 Advanced Nursing Practice : A NationalFramework
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mpact of Advanced
Nursing Practice
Advanced nursing practice has evolved to meet the
demands of modern health care through
increasingly advanced 9no!ledge and s9ills.
It is not merely technical and educational
progress that has driven the development of
advanced nursing practice the health needs
of clients and the gro!ing comple3ity of care
have also contributed.
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Advanced practice nurses
have used their experienceAdvanced nursing practice has evolved to meet the
and education to take nurs -demands of modern health care through increasingly
ing practice to new levels ,
as the! have moved from a
supportive to a leading role in
client care .
advanced 9no!ledge and s9ills. It is not merely technical
and educational progress that has driven the
development
of advanced nursing practice the health
needs of
clients and the gro!ing comple3ity of care
have also
contributed. Advanced practice nurses have
used their
e3perience and education to ta9e nursing practice to ne! levels,
as they have moved from a supportive to a leading role in client
care.
vidence about the bene6ts of advanced nursing practice is no!
building. Cunningham
>*''2, p. *+5? has stated that nurses in advanced nursing practice
FenrichG health care by
adding value to the delivery of health$care services. Bryant$8u9osius,
DiCenso, Bro!ne
and inelli >*''2, p. &*? found that advanced practice nurses may
improve client and
health$care system outcomes related to health status, functional
status, uality of life,
satisfaction !ith care and cost e=iciency. De:rasse and Nic9lin
>*''+, p. 1? reported
that the use of advanced practice nurses decreased
the number of hospital admissions and emergency
0Clinical nurse specialists , with
their focus on patient care from a
nursing perspective , can advance
nursing practice through education,
research and the development of
s!stems that meet patient and
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famil! needs . 1
, 6rlene 3ea&orne/ clinical nurse secialist
5amilton/ 7ntario
#0
department visits, shortened lengths of stay and
resulted in cost savings for the institutions
!here they !ere employed. (ther
outcomes that improved !ith advanced
nursing practice included fe!er
readmissions for heart failure, shorter
lengths ofstay !hen patients !ere readmitted and
lo!er rates
of urinary tract infections, s9in
brea9do!n and
pneumonia >)leinpell, *''0, p. *'?.
)leinpell also reported that advanced
nursing practice helped
promote evidence$based care, improved patients
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0Clinical nurse specialists support and
teach other health -care providers and
adherence to health promotion and builtthe
evidence base of nursing. Advanced
nursing practice is an innovative and
e3citing develop$
ment that provides nurses !ith an
opportunity to !or9 at an advanced
level of clinical practice >"urlong H
4mith, *''&, p. +'*?.
can in7uence and improve health care
at the individual and the s!stem level . 1
, 8inda 9ead Paul/ clinical nurse
secialist'algary/ Al&erta
The role of the nurse practitioner has been studied for many years. In a literature
revie! commissioned by the College of 7egistered Nurses of Nova
4cotia and released in @une *''0, 4angster$:ormley reported that
client satisfaction and education are the most commonly researched
outcomes of nurse practitioner care. Jo!ever, the author !ent on to
describe solid evidence for many other bene6ts to care- nurse
practitioners are more li9ely to follo! practice guidelines, and their
patients have shorter stays, fe!er readmissions and other
successful outcomes.
The body of research on advanced nursing practice is smaller than
is the case for many
other topics in nursing. In another revie! of recent research,
(erman and "loyd
>*''*, p. +2'? identi6ed and described this lac9 of evidence. They
found that researchon outcomes has focused too much on cost savings, ignoring
important aspects of the
!or9 of advanced practice nurses such as resolution of symptoms,
enhancement of
clients uality of life and improvements in 9no!ledge among
patients and families.
They called for advanced practice nurses to lead more research on theresults of speci6c
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nursing interventions.
"or their annotated bibliography, published in *''2, "ulton and
Bald!in revie!ed
0' research papers that had been !ritten by nurses or had
e3amined the impact of
clinical nurse specialists. "ulton and Bald!in identi6ed many
!ays in !hich clinical
nurse specialists improved care, such as reducing the number of
visits to emergency
departments by clients !ith asthma and improving prenatal care
of and generating
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better outcomes for very lo! birth !eight babies they also found that cancer
patients !hose care team included a clinical nurse specialist had
fe!er complications. erhaps the most important aspect of the
article !as the scope of information it
covered- in addition to the research pieces, the authors revie!ed /+
publications about
program development and evaluation and *& anecdotal accounts.
These numbers are
a sign that the 9no!ledge base for advanced nursing practice is
building, but "ulton
and Bald!in >*''2, p. **? !arned that Falthough the number of
articles had drastically
increased, the scope of everyday Lclinical nurse specialistM
accomplishments is not
completely captured in published !or9. LClinical nurse specialistsM
improve care
practice on a daily basis.G
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:upport for Advanced
Nursing Practice
Advanced nursing practice must be supported at many
levels if it is to operate e=ectively and provide a full
range of bene6ts to clients, other members of the
health team, organiations and the community as a
!hole.
Advanced Nursing Practice : A National Framework ##
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Advanced nursing practice must be supported at many levels if it is to
operate e=ectively
and provide a full range of bene6ts to clients, other members of the
health team, organiations and the community as a !hole. The
;niversit! ;icevs9i et al., *''2, p. &/?.
To ourish, advanced nursing practice needs-
E leadership by CNA, other nursing organiations and
governments to encourage creation of positions for nurses in
this type of practice
E leadership by CNA and other nursing organiations to
identify opportunities for the introduction of future advanced
nursing practice roles that align !ith current and emerging
population health and system needs
E health human resources planning that ta9es a pan$
Canadian, interprofessional approach and that is based on a
conceptual frame!or9
E organiational and administrative support and resources to
implement, develop and sustain various aspects of advanced
nursing practice
E communication and education tools to inform the public, policy$
ma9ers, adminis$
trators and other professions about the contributions of advanced
nursing practice
E human resources policies that allo! nurses to pursue graduate education
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E specially designed graduate curricula based on the
characteristics and competencies of advanced nursing
practice
E e3ible path!ays to graduate nursing education
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E support for professional development and lifelong learning
E funding for research about and by nurses in advanced nursing practice
E interprofessional education and organiations that foster team !or9
E resources to put in place the positions, technology,
administrative infrastructure and culture for advanced practice
nurses to !or9 most e=ectively and
E policy processes that promote advanced nursing practice and
are shaped by the e3pertise of advanced practice nurses.
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8ooking to the $uture
Canadas health$care needs are gro!ing
!ith the aging of the population, continued
shortages in the supply of health human
resources, increasing comple3ity of the health$
care system and mounting pressure to contain
costs. Advanced nursing practice is helping
to meet these gro!ing needs. To have a far$
reaching impact, ho!ever, advanced nursing
practice must be promoted and sustained.
Advanced Nursing Practice : A National Framework #*
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Canadas health$care needs are gro!ing !ith the aging of the population, continued
shortages in the supply of health human resources, increasing
comple3ity of the health$care system and mounting pressure to
contain costs. Advanced nursing practice is helping to meet these
gro!ing needs. To have a far$reaching impact, ho!ever, advanced
nursing practice must be promoted and sustained.
Ne! advanced nursing practice roles should be introduced only in response to the health$
care needs of Canadians and must be based on solid evidence of those
needs. CNAs position statement National Planning for Bryant$8u9osius H DiCenso, *''2, p. &/+
*''2, p. &/*? presented
the A
frame!or9, a Fparticipatory, evidence$based,
patient$centred
process for Ladvanced nursing practiceM role
development,
implementation and evaluation,G !hich set out
nine steps for
determining !hether a ne! advanced nursing
practice role is
needed and !hether it !ill be e=ective. These steps include de6ning
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the patient population, de6ning ne! models of care and the place of
the advanced practice nurse !ithin them, implementing the ne!
models of care and long$term monitoring.
The Canadian Nurse ractitioner Initiative includes an
implementation and evaluation
tool9it, !hich serves as a practical guide to assessing the need and
readiness for the nurse
practitioner role. In addition, the tool9it identi6es 9ey steps and
factors to support the
implementation of this role and ongoing monitoring of its
e=ectiveness through a
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structured, for!ard$loo9ing evaluative approach. In particular, the tool9it
o=ers guidance on
tailoring the planning, implementation and evaluation of the nurse
practitioner role to the
uniue reuirements of speci6c practice settings. The design of the tool9it
!as based on the
A frame!or9, e3tensive literature revie! and e3perimental research,
9ey sta9eholder con$
sultation and a revie! of best practices >CNA, *''d?. In addition, a
needs$based simulation
model for health human resources planning !as developed in conunction
!ith the Canadian
Nurse ractitioner Initiative this model is applicable to primary health
care nurse practitioners
across all urisdictions in Canada. It goes beyond the traditional planning
models, !hich are
based on supply and proected population$to$provider ratios, to consider
population health
needs and the level of services reuired to meet those needs >CNA,
*''e?.
Coordination of the preparation and roles for advanced nursing practice is
another necessary step. The development of educational and e3periential
goals and programs for advanced practice nurses should be aligned
across the provinces and territories, to reinforce their place in health care
overall and to permit labour mobility. The goal must be to ensure that all
Canadians have access to similar types of e3pertise.
To e=ectively develop and sustain the health$care system, the roles of health$care providers,
including advanced practice nurses, must be optimied. Canadians can
anticipate many ne! chal$
lenges to their health$care system, including increases in chronic diseases
such as diabetes mellitus
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and arthritis. Nonetheless, a shift in focus from illness to health is e3pected,
!hereby clients !ill
become more educated and more strongly engaged and !ill participate more
actively in developing
and maintaining their o!n health >illeneuve H ;acDonald, *''?.
Advanced practice nurses
must be part of the solution to these health$care challenges and the changes
that lie ahead.
Ne! approaches to health care, based on strategies that !ill enhance
access to service delivery !hile improving the health of the population,
must be developed collaboratively.
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=lossar!
Advanced nursing practice
Ombrella term for an advanced level of clinical nursing
practice that ma3imies the use of
graduate educational preparation, in$depth nursing
9no!ledge and e3pertise in meeting the
health needs of individuals, families, groups, communities
and populations. It involves-
E analying and synthesiing 9no!ledge
E understanding, interpreting and applying nursing theory and researchand
E developing and advancing nursing 9no!ledge and the profession as a!hole.
Client The bene6ciary of care may be an individual, family, group,population or entire
community
Client-centred care
FNurses achieve client$centred care by actively includingthe client and signi6cant others
as partners in the care, Land byM identifying the clients
goals, !ishes and preferences
and ma9ing these the basis of the plan of care...G
>College of Nurses of (ntario, *''?
Clinical nurse specialistA registered nurse !ho holds a masters or doctoral
degree in nursing !ith e3pertise in a clinical nursing
specialty uses in$depth 9no!ledge and s9ills, advancedudgment and
clinical e3perience in a nursing specialty to assist in
providing solutions for comple3
health$care issues
Competencies
Credentials
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$0Integrated 9no!ledge, s9ills, udgment and personal attributes reuiredof a registered
nurse to practise safely and ethically in a designated role and setting>CNA, *''&?
;ar9s or FstampsG of uality and achievement
communicating to employers, payers and
consumers !hat to e3pect from a FcredentialedG nurse,
specialist course or program ofstudy, institution of higher education, hospital or health
service, or health$care product,
technology or device
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=raduate education
ducation beyond the baccalaureate level, including
masters, doctoral and postdoctoral levels >"ield, 4tinson
H Thibaudeau, +55*?
&entoring A voluntary, mutually bene6cial, long$term relationship in !hich ane3perienced and
9no!ledgeable leader >the mentor? supports the
maturation of a less e3perienced nurse !ith leadership
potential >the FmenteeG?
Nurse practitioner
A registered nurse !ith additional educational
preparation and e3perience !ho possesses and
demonstrates the competencies to autonomously
diagnose, order and interpret diagnostic tests,
prescribe pharmaceuticals and perform speci6c
procedures !ithin the legislated scope of practice
>CNA, *''a?
egulation All of those legitimate and appropriate means $ governmental,professional, private and
individual $ !hereby order, identity, consistency and
control are brought to the profession through regulation,
the profession and its members are de6ned, the scope of
practice is determined, standards of education and of
ethical and competent practice are set and systems of
accountability are established >4tyles H A=ara, +550?
:cope of nursing practice
The activities that nurses are educated and authoried to
perform, as established through legislated de6nitions of
nursing practice, complemented by standards,
guidelines and policy positions issued by professional
nursing bodies >CNA, *''&?
:pecialized practice
ractice that concentrates on a particular aspect of nursing, related tothe clients age
>e.g., pediatrics, gerontology?, the clients problem >e.g.,pain management, bereavement?,
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the diagnostic group >e.g., orthopedics, vascular
surgery?, the practice setting >e.g., home
care, emergency? or the type of care >e.g., primary
health care, palliative care, critical care?
Advanced Nursing Practice : A National Framework $1
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Appendix A
PPPA $ramework
Participator!, evidence-based, patient-centred process for advanced practice nurse >APN?
role development, implementation and evaluation
From: -ryant,ukosius/ 4"/ 4i'enso/ A" 1200$" A framework for the introduction of an evaluation ofadvanced racticenursing roles" ;ournal of Advanced Nursing/ $8 1%/ %#0,%$0" 9erinted with the ermission of -lackwellPu&lishing"
$2 Advanced Nursing Practice : A National
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Framework
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Appendix )
6he Consultation Process
The Board of Directors of the Canadian Nurses Association >CNA?
approved the 9ey elements of a national frame!or9 for advanced
nursing practice in @une +555. The frame!or9 !as 6rst published
in ;ay *''' in Advanced Nursing Practice# A National $ramework.
In ;arch *''*, the CNA Board of Directors revised one of the 9ey
elements of the frame!or9 by establishing a graduate degree in
nursing as the minimum educational reuirement for advanced
nursing practice
Changes in practice that emerged during CNAs *''& Dialogue on
Advanced Nursing ractice and the Canadian Nurse ractitioner
Initiative >*''2$'? signalled the need to update CNAs frame!or9
on advanced nursing practice.
In *'', the CNA Board of Directors created a national !or9ing
group to guide revision
of the frame!or9. Its consultations involved one face$to$face
meeting, numerous tele$
conferences and circulation of several draft documents among
member urisdictions
and national nursing and other health$care organiations. In
addition, a discussion of
the draft frame!or9 by the CNA Board of Directors helped to guide
the 6nal version.
"eedbac9 from the consultation process !as e3tensive. Jundreds of responses !ere
received from associations, organiations and individual nurses.
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Although vie!s on speci6c
aspects of the frame!or9 di=ered, there !as strong consensus on the
9ey concepts for
advanced nursing practice. Ta9ing into consideration the feedbac9
received and the con$
sensus recommendations from the national !or9ing group, the CNA
Board of Directors
approved the updated frame!or9 for advanced nursing practice in
November *''0.
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Appendix C
&embers of the National /orking =roup
Co-Chairs
Christine ieck )uckle! Canadian Nurses Association
*ebbie PhilipchukCollege @ Association of egistered Nurses of Alberta
&embers
aren Antoni Canadian Association of Advanced Practice Nurses
=ail )eatt! egistered NursesB Association of ntario
&ichDle )rennanCollege of egistered Nurses of Nova :cotia
:uzanne *urand rdre des inrmiDres et inrmiers du EuFbec
:tephen 8eck egistered Nurses Association of Northwest 6erritories and
Nunavut
$rancis 8oos :askatchewan egistered NursesB Association
)ett! 8undriganAssociation of egistered Nurses of Newfoundland and 8abrador
Patricia &c=arr Gukon egistered Nurses Association
)lake Parkin Association of egistered Nurses of Prince dward sland
Cheri Higar College of Nurses of ntario
)arb /aters Nurse Practitioner Council of Canada
Io /earing College of egistered Nurses of )ritish Columbia
*oug /heeler Nurses Association of New )runswick
Ioanne /insor College of egistered Nurses of &anitoba
$$ Advanced Nursing Practice : A NationalFramework
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eferences
Association of 7egistered Nurses of Ne!foundland and 8abrador.
>*''0?. Advanced practice-clinical nurse specialist Losition
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