Advanced practice nursing in Canada is receiving attention locally and nationally as gaps in our healthcare system persist, specifically as they relate to access to care and wait times. Nationally, nurse practitioners (NPs) and nursing leaders have developed documents that begin to define the foundation required for the successful introduction, evolution, evaluation and sustainability of the NP role (Bryant-Lukosius and DiCenso 2004). Much work has been done to promote the role of the nurse practitioner across Canada as provinces and territories learn from one another and overcome barriers to furthering this advanced practice nursing role (CNA 2006).

The context within which the NP role is being implemented across Canada is important. The role has the opportunity to evolve as a catalyst for change that may strengthen our collective thinking about nursing in a preferred future. Today, healthcare is defined as a "Canadian value" as access to publicly funded services increasingly becomes a focus for concern across the nation. If we are to sustain our publicly funded healthcare system, transformation is required - along with a paradigm shift for clinicians from all healthcare professions, administrators, regulatory and legislative bodies, policy makers at all levels of government across ministries and sectors, and the general public. A main focus on illness and treatment of disease must be re-balanced to include an orientation based on wellness and holistic care, with greater emphasis on prevention of disease, illness and injury (Villeneuve and MacDonald 2006). At the same time, continued treatment of existing health problems is required, with a focus on self-care. These fundamental values are embedded in the current nursing paradigm and can help lead the way as new care delivery models are introduced.

What are the opportunities for nurse practitioners to build on their role, today and into the future?

Our current healthcare system is largely provider-centric by design and must transform into a system that is more person-centric, in which Canadians are supported to assume greater accountability for their health status and are empowered to manage their own healthcare needs. Technology will play a significant role here. Imagine a society where technology is more pervasive, smaller and less expensive, and where populations are better informed because information is more readily available and shared as an enabler for self-care. Imagine a healthcare system in which people partner with providers in an electronic circle of care to co-manage their care across the system, where screening and prevention, as well as chronic disease management through automatic prompts, are established as standard practice. By the year 2020, "baby boomers" will be the demographic driving force and will need care closer to home. Imagine diminished boundaries among health sectors, with greater sharing of resources as the electronic health record enables and integrates all health information.

Increasingly, cultural diversity will be the Canadian context within which health and wellness, as well as treatment of disease, will be shaped. Complementary and traditional healthcare will converge. By the year 2020, many people will have a genetic profile, and many will have coaches to assist them in maintaining health across the lifespan. Older people will need a focus on chronic disease management, while younger people will be healthier than those today. Teams, assisted by technology, will be the fundamental approach for healthcare delivery. New healthcare roles will emerge. Some roles of today will no longer exist, while others will change.

Imagine a future in which healthcare funding is aligned to a new pyramid structure, and primary care is fundamental and more predominant and serves as the basis for the system. Hospitals will provide only tertiary care; connections among primary, community and acute care settings will be seamless, and care will be coordinated and integrated across sectors. Heightened awareness of the social determinants of health, and new and different strategies to address them, will be required to promote Canadian population health. What if policy decisions of the future were intersectoral, with recognition that promotion of population health includes more than just healthcare?

This is the context within which the vision of the nurse practitioner's role must evolve. A focus on person-centred care that supports people in health and illness to live intact, meaningful lives will be a unique contribution of NPs. Strong interprofessional collaboration and consultation will be key success factors. Healthcare delivery will be defined by high-functioning teams providing care in intentionally designed systems, in which evidence-based practice and quality assurance are achieved through collaborative efforts to reduce harm, promote wellness and prevent illness and injury, as well as treat illness and disease.

Dr. Paul Uhlig (2006) describes nurse practitioners as a "disruptive innovation." As such, they have the potential to be a catalyst in the process of achieving the transformed healthcare system described above. In fact, the impact of many NPs as a disruptive innovation is already being felt to varying degrees across Canada as their roles evolve to challenge current and old models of care across the system in primary, acute and long-term care, and in urban, rural and remote settings. Desired outcomes of NP practice must be planned and patient-centric, and must demonstrate the "value added" aspect of the NP role to the team, defined by outcomes of care at the patient, organizational and healthcare system levels. These outcomes can then inform continued role development to facilitate the transformation of healthcare delivery models.

Effective NP role implementation and positioning for the future must be intentionally designed as NP practices evolve to bridge the gap associated with shortages in medical care. The need to demonstrate, articulate and publicize the differences in approach to care by nurse practitioners is critical. Attention to unmet healthcare needs and the creation of therapeutic "micro" cultures that are team based and patient/family centred will be important foci. Within all professional disciplines, cultural assumptions that interfere with good communication and collaboration must be identified and strategies developed to overcome barriers to effective team approaches to care. Attention must also be paid to applying ongoing and existing research for improved patient, organizational and system outcomes. Research identifying barriers to full scope of practice for NPs must be addressed at the political level to effect real and lasting change that will ensure the sustainability of our healthcare system.

Recommendations for effective and sustained NP role implementation are published in the final report of the Canadian Nurse Practitioner Initiative (CNPI), following a broad consultative process with a variety of healthcare professionals; federal, provincial and territorial professional associations; regulatory bodies; and employers, unions and governments (CNA 2006). This initiative was funded by Health Canada and was led by the Canadian Nurses Association. Broad recommendations include practice and evaluation frameworks and toolkits; legislation and regulation; health human resources planning; education and strategic communications; and change management and social marketing. The report proposes a pan-Canadian nurse practitioner definition and emphasizes the need for adoption of a common definition and description of NPs' role that illustrates the healthcare contributions they can make. It also highlights the need to anchor collaborative and consultative team-based practice in patient-centred care. Recommendations call for the integration of NP roles into interprofessional teams in which roles and accountabilities are clear.

The CNPI report further calls for funding and remuneration mechanisms that support team-based collaborative practice delivery models, with the identified observation that fee-for-service does not work in these new care delivery models. It identifies non-restrictive legislative and regulatory frameworks as a need both to protect the public and to allow evolution of the profession with mobility options across Canada. The report also addresses the need for title protection, clarity for the NP scope of practice, professional autonomy, accountability and responsibility, standard educational requirements and national accreditation of educational programs. It underscores the importance of provincial and territorial funding dedicated to the sustainability and integration of NPs. Key themes for health human resources planning for NPs include a pan-Canadian, interprofessional approach that is based on a proposed conceptual framework; development of long-term funding policies; and remuneration to reflect NPs' scope of practice, responsibility and accountability. Such remuneration would take into account discrepancies in salary and benefits, annual cost-of-living expenses, incentives and supports to retain NPs in difficult-to-recruit areas, as well as consideration for additional overhead, operating and infrastructure expenses. Also recommended is the need to enable full role utilization of advanced practice nursing skills to achieve a blend of individual and family visits, population health initiatives and research.

The CNPI report emphasizes the need for creating healthy work environments as key recruitment and retention factors for NPs. Strategies to achieve these include enabling NPs' full scope of practice as well as professional development, infrastructure support, availability of information, communications and computer technology and participation in decision-making. Ongoing attention to change management, social marketing and strategic communication with stakeholders and target audiences is the final broad category of recommendations. While the report is targeted towards enabling NP practice in primary care, many of the recommendations could be adapted to other healthcare settings.

How we work at the provincial and national levels to influence needed changes and learn from one another will be critical. Many of the recommendations in the CNPI report would address some of the barriers to full integration of primary healthcare nurse practitioners identified by DiCenso and Matthews (2005). Policy- and decision-makers need to become familiar with, and act to implement, recommendations for the full integration of nurse practitioners into our healthcare system. They must demonstrate their willingness to listen to our capable and willing interprofessional teams, who are passionate for change that enables them to improve outcomes for patient, family and community health. Indeed, interprofessional teams are asking policy- and decision-makers to get on with the work of implementing strategies to overcome identified barriers to new models of practice.

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